Save of the Day: AAA #1

Ok folks, I’ve been wanting to post this one for a while. I don’t often (read: ever) say this, but I’m convinced that I truly saved a life the other day. Now, coming from an emergency physician that may seem like a humble-brag or a not-so-subtle compliment-fishing expedition, but I’ll remind you that I’m constantly surrounded by healthcare professionals that are significantly smarter and better than me, so any save I make could almost certainly be made (and better) by any one of my incredible colleagues. In this case, though, I found myself in a situation in which I feel that I was uniquely qualified and equipped to intervene. Having said that, let’s get to the case…

The Setup

The patient in question was signed out to John Krogh and I one afternoon. She had a history of a TAAA (thoraco-abdominal aortic aneurysm) that had previously been repaired from her mid-arch all the way through her iliac arteries (whoa…) and had a known endoleak with a fairly large false lumen in the abdomen (double whoa…).

She had been to the hospital several times over the prior year, initially for her staged aortic repair and several subsequent repairs related to the persistent leak. More recently, she had presented several times to the ED for abdominal pain and vomiting, including ~2 weeks prior to this visit, and these symptoms had been responding fairly well to acid-suppressants and antiemetics. The pain she experienced the morning of my encounter with her was described a bit differently than her prior pain, and did not respond as well to GI meds, but had not worsened or significantly changed during the course of the day. At the time of sign-out, she had had labs drawn that were reassuring and she was awaiting a CT to evaluate her aorta (see above images).

Proximal TRV
Mid-abdominal aorta with endograft (bright while circle) containing true lumen and surrounded by large false lumen. No definite signs of active extravasation of contrast material.

Around an hour after sign-out, she had her CT, which John and I looked at quickly. It appeared to show a large endoleak, but no signs of active extravasation as far as I could tell, and the false lumen looked pretty homogenous all the way down. We were, however, struck by the impressive size of the false lumen (see above). These impressions were corroborated shortly thereafter by a call from the radiology fellow, who felt that her false lumen size had increased a decent amount but agreed there were no signs of active or imminent rupture. Thus, John went to re-evaluate her prior to disposition, which would have most likely been touching base with CT surgery and eventually a likely discharge home.

It Hits The Fan

About 2 minutes after going to the patient’s room, John called me and told me to come there as soon as possible. I entered the room to find the patient bent over in horrible pain. John told me she had developed lower chest and upper abdominal pain radiating to her back only minutes before. Fearing the worst, I immediately pulled out my Lumify probe and took a look. My first concern was for rupture of the wall of the true lumen with retrograde dissection into the pericardium, so my first step was an echo, which did not demonstrate a pericardial effusion. I moved on to a FAST exam to evaluate for free fluid in the abdomen, of which there did not appear to be any (although my phased array probe is less than ideal for a comprehensive search for free intraperitoneal fluid). Finally, I peeked at her aorta.

Transverse view of the proximal abdominal aorta

On first glance at the clip above, my thought was that the large anechoic spot in the aorta was the true lumen (yellow outline in the large image and top right image below), surrounded by the relatively homogenous false lumen filled (presumably) with clot (green outline). On closer look, though, I realized that I could actually see the endograft just below that area (yellow circle bottom right picture) and within the false lumen (green circle), which meant the other anechoic area (red circle) was something new. Even more concerning was the irregular edge of the anechoic space that appeared to be changing as I looked (red arrow).

Altogether, this was an extremely concerning picture for an active rupture developing before our eyes. All that was left to do diagnostically was to prove it beyond a doubt. Ladies and gentlemen, I present to you the single most pride- and fear-inducing ultrasound clip of my career so far:

Color extravasation
Active extravasation into the false lumen. Definitive evidence of active rupture. Not seen on CT less than 30 minutes prior.

Case Conclusion

On seeing the image above, John and I quickly moved the necessary pieces into place. We obtained additional IV access, started the patient on an esmolol drip for BP control and to lower the shear force on the wall of the aorta, cross-matched her for multiple units of blood, moved her to the resuscitation bay in the ED, and called vascular and CT surgery. On arrival in the ED, I showed my scan to the CT surgery fellow, who immediately pivoted from recommending a repeat CT to a somewhat surprised “Oh…that’s awesome! Can you email those images to me? I’ll show them to my attending and we’ll get her to the OR as soon as we can.”

The patient ended up going to the OR shortly thereafter, and after surgery and several days in the SICU, was able to walk out of the hospital alive, which I firmly believe was due in large part to the presence of a trained provider at the bedside in her time of greatest need and the immediate availability of a tool that likely shaved dozens of minutes off of her time-to-diagnosis in a situation where seconds count. My conclusion? Any provider who tells you they just don’t trust an “informal” ED bedside ultrasound should talk to a patient whose life was saved the probe. I think my patient would feel somewhat differently about the issue.

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