A 78-year-old man is brought to the emergency department with sudden onset severe constant mid-back and abdominal pain. He is pale, diaphoretic, and has a pulsatile epigastric mass. Blood pressure is 80/50 mmHg. The MOST appropriate next action is:

• A Urgent CT angiography of the aorta to confirm diagnosis and plan EVAR
• B Immediate transfer to operating theatre for emergency open or endovascular aortic repair — further imaging should not delay surgery in a haemodynamically unstable patient ✓
• C Echocardiography to rule out aortic dissection before surgery
• D Resuscitation with crystalloid to BP >120 mmHg, then CT scan

Explanation

This clinical picture — pulsatile abdominal mass, severe pain, and haemodynamic instability — is a ruptured AAA until proven otherwise. This is a surgical emergency with mortality of 80–90% without surgery. The haemodynamically unstable patient with suspected ruptured AAA should be transferred directly to the operating theatre without delay for imaging. CT is used for 'haemodynamically stable-enough' patients where EVAR is being considered; it is contraindicated in true haemodynamic instability. Over-resuscitation (targeting normal BP) may worsen haemorrhage by dislodging the retroperitoneal haematoma clot.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.