4. Ruptured Abdominal Aortic Aneurysm

An 81-year old lady presented to the emergency department 7 h after sudden onset of left Join and abdominal pain. Her past medical history was unremarkable, apart from hypertension. She had not smoked for 25 years. On examination, she was pale and obese, her pulse was 110 bpm, and her blood pressure was 110/40 mm Hg. There was also left flank and loin tenderness. Initial investigations, including urea and electrolytes, creatinine, amylase, full blood count, electrocardiogram (ECG), and chest and abdominal X-rays, were normal apart from an elevated creatinine at 160 !Jmol/1 and a haemoglobin level of only 10.1 g/dl. The emergency room doctor made a provisional diagnosis of left renal colic and referred the patient to the urology service. The on-call urologist found that there was no previous history of renal tract disease, the patient's urine was negative for blood on testing, and the patient had developed a pulsatile mass on the left side of the abdomen. An urgent ultrasound scan was requested, but before the investigation could be performed, the patient's blood pressure dropped to 80/40 mm Hg. The patient was referred to the on-call vascular surgeon because of a suspected ruptured abdominal aortic aneurysm {AAA). The patient's blood pressure stabilised at 100/40 mm Hg following administration of 500 ml colloid, and no further fluid was given. Ten units of packed red cells, as well as fresh frozen plasma (FFP) and platelets, were requested. After a discussion of the risks and benefits of surgery with the patient and the next of kin, the patient was taken to the operating theatre.