A 72-year-old male with a known 4.8 cm infrarenal abdominal aortic aneurysm (AAA) presents with sudden severe back pain, hypotension, and a pulsatile abdominal mass. CT scan shows a contained retroperitoneal hematoma. What is the immediate management?
- A Aggressive fluid resuscitation to SBP > 120 mmHg before operative intervention
- B Aortic balloon occlusion via interventional radiology, then medical management
- C Permissive hypotension (target SBP 50–70 mmHg) while arranging EVAR or open repair ✓
- D Observe in ICU; CT shows contained rupture so surgery can wait 24 hours
Explanation
For suspected ruptured or symptomatic AAA with contained retroperitoneal hemorrhage, the principle of permissive hypotension (target SBP 50–70 mmHg) limits ongoing hemorrhage while preserving vital organ perfusion until operative repair — aggressive fluid resuscitation drives blood pressure up, disrupting the tamponade and worsening bleeding. The choice between emergency EVAR and open repair depends on anatomy and institutional resources; EVAR has lower 30-day mortality in suitable anatomy. Time to theatre is critical — in-hospital delays worsen outcomes. Aortouniiliac EVAR with femoral crossover is an option for emergency EVAR.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.