# Triple A



## Patterson0817 (Feb 13, 2013)

Brain fart....what's the right procedure for an INTERMEDIATE to handle a triple a?


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## STXmedic (Feb 13, 2013)

Transport...


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## DrParasite (Feb 13, 2013)

IIRC, two large bore IVs to keep the BP above 90, keep the patient supine, and drive really really fast to the hospital, making sure they have a surgeon waiting for you when you arrive in the ER, because only surgery will save the patient (and that's not even guaranteed).


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## Christopher (Feb 13, 2013)

DrParasite said:


> IIRC, two large bore IVs to keep the BP above 90, keep the patient supine, and drive really really fast to the hospital, making sure they have a surgeon waiting for you when you arrive in the ER, because only surgery will save the patient (and that's not even guaranteed).



Pain control (if I's can do that), ensure Y-sites or blood tubing are present, strip the patient down and gown them, online med control to see if they want you to control BP via nitrates.


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## Veneficus (Feb 13, 2013)

PoeticInjustice said:


> Transport...



This.




DrParasite said:


> IIRC, two large bore IVs to keep the BP above 90, keep the patient supine, and drive really really fast to the hospital, making sure they have a surgeon waiting for you when you arrive in the ER, because only surgery will save the patient (and that's not even guaranteed).



Keeping the BP above 90 will not matter.

If there is a significant rupture prehospital, the 30 day mortality is between 95% and 100%. The best save rates in the entire world are 87% mortality in 30 days. Unless you are going to that center, don't get too excited.

You do need to not only go to a surgeon, you need to go to a center that will operate on it. Many centers simply will not, even if they have an in house surgeon.

If you pump fluid into this patient, they will likely die. 90mmhg systolic is based on a very conservative safety measure for renal failure. But if you are preventing clotting and increasing intravascular pressure in a ruptured AAA you waste your time. The physiologic shock response is the best protection there is for the patient. Don't mess with it. 

If you have a protocol that dictates otherwise, then just do it and write the pt off. Not worth losing your job over a person likely going to die no matter what. 




Christopher said:


> Pain control (if I's can do that), ensure Y-sites or blood tubing are present, strip the patient down and gown them, online med control to see if they want you to control BP via nitrates.



You can do this too. But if there is no rupture, just keeping pain under control and going to the right place will be your best chance. Some places do not have such centers in their transport area.


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## VFlutter (Feb 13, 2013)

Do you carry any beta blockers?


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## RocketMedic (Feb 13, 2013)

Case 2: 58 y/o M c/c ear pain. Became dizzy at work, got ride home, started drinking, pain didn't stop. Calls us, fire walked him downstairs as we rolled up. Tries to cancel us, concerned that "he'll be in the system" and can't afford a ride. I convinced him to let us assess him- and he starts telling us how the pain is starting in his ear and moving down the right side of his neck into his chest with radiation down the right arm and complaints of weakness, numbness to right arm. Obviously, this bought him a 12-lead, noting V2/V3 ST-elevation, RAD, LVH and a sinus arrythmia. Pressure was 150/100 left 140/100 right (written off as a calibration/cuff size error, honestly never thought to recheck it manual/both sides once I had the left-side manual), no medical history known, cigarettes and alcohol, no meds. Patient also complained of weakness and pain in his arm when raised above shoulder level and exhibited slightly less grip strength to the right hand. Very vague in complaints, denied any other pain. Lung sounds diminished/equal, SpO2 97%, capnography normal, BGL 80, abdominal assessment normal. 12-lead right side normal with V2 and V3R still noting ST-elevation. Blood pressure was about 8-10 points different between right and left arms (I didn't pick up on this, my error). Pain 8/10 relieved with nitro to 5/10, repeated q5 x2 with total relief of chest pain, aspirin given en route- thinking septal or right-lateral MI, potentially angina or something. Turned out to be a dissection of the aorta in the mid-thoracic noted on the hospital's CT scan- normal abdominal assessment, slightly ACS-looking 12-lead. He went to surgery about an hour after it was recognized, had it repaired, and is stable.

I feel bad for missing it, but it was a fairly atypical presentation. Who would have thought ear pain and dizzyness with ETOH would turn into a dissected aorta? Did the NTG and ASA hurt him? How do you recognize non-traditional AAA? Thanks!

*Posted for broader discussion, I learned something from this. 
PROS:
Didn't let him stay home (not kidnapped, but didn't chase a refusal either). Right facility with surgical staff (luckily, this would have been hard to screw up, but I wanted a place with vascular-surgical capabilities on the thought that it might be an MI, and here in OKC, both OU and Holy Tony's have that. If he'd said something like "I want to go to Kindred" or "Canadian Valley", that would have been a problem. Gatekeeper mode on!

Didn't push any fluid. Pressure was mildly hypertensive. One trick I learned from my dad is I won't connect fluid unless I'm going to run it, so I'll have a bag spiked and ready if the patient may need fluid, but I don't leave a bag connected to the lock if I may be infusing anything _unless_ I actually need to infuse it. 

Didn't undertriage him: Vague nonspecific complaints that start with "my ear hurts" unfortunately tune a lot of us out. If I'd have cued on that and started with the HEENT train of thought, I'm not sure what I could have ended up with. 

UNKNOWNS: ASA 324mg PO + 0.4mg NTG SL q3 with relief of pain, thought it was an infarct of some kind. No nausea, urge to defecate, back pain, masses, completely normal physical assessment with no back pain, nothing abnormal in the abdomen, skin normal tone/dry/warm, pupils 4mm/equal/reactive, lungs indicative of smoking x lots of years...honestly, this man stumped me. I was thinking MI (due to the 12-leads and right-sided 12-leads, possibly a septal or anterior presentation), or _maybe_ a PE in terms of chest problems, or possibly a respiratory infection or strep or something, or an ear infection. Afebrile. Nitro dropped his pressure to 116/80 with complete relief of pain.

CONS: Honestly didn't consider the possibility of aneurysm. I thought that would be "shocky with no root cause", "palpable mass in the abdomen", "tearing back pain" and/or nonspecific chest and back pain with hypotension and obvious signs of shock.

This is what ERs are for, I reckon- people with far more knowledge, skill and equipment than I have making sense of the confusing. From the follow-up, I don't get the impression that it was a rupture, but the staff seemed to think it was interesting enough to mention to me on my return trip.


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## Christopher (Feb 13, 2013)

Chase said:


> Do you carry any beta blockers?



Metoprolol at one service (SVT/AF), Labetalol at another (HTN).


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## Christopher (Feb 13, 2013)

Rocketmedic40 said:


> Obviously, this bought him a 12-lead, noting V2/V3 ST-elevation, RAD, LVH and a sinus arrythmia.



If I had to bet the ST-E in V2/V3 was normal for his LVH.

I wouldn't feel so bad about triaging this as ACS as a non-zero number of AAA patients go to cath for STEMI! I've yet to have a non-transfer AAA that was "classic presentation". All have been something other than textbook.


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## Veneficus (Feb 13, 2013)

Rocketmedic40 said:


> CONS: Honestly didn't consider the possibility of aneurysm. I thought that would be "shocky with no root cause", "palpable mass in the abdomen", "tearing back pain" and/or nonspecific chest and back pain with hypotension and obvious signs of shock.



I already sent you a PM. 

But, I would like to point out here:

there are 5 major types of "aneurysms." Thoracic, abdominal, cerebral, limbs, and the often misnamed pseudoaneurysm. (usually found in the thorax) 

Abd, has multiple classes of aneurysm, 3 or 4 depending on who you ask or what book you read. (basically some classify it on appearance of involvement of the renal arteries others don't)

abd, cerebral, and limb aneurysms all have a common pathophysiology. 

Thoracic and pseudoaneurysms have different pathology than the others.  Mostly important for clinical identification (like catostrophic aortic valve failure or insufficency) and type of definitive repair most applicable.

Whaht you described above is a rupture of a AAA. The hypotension is only seen after extreme blood loss from massive rupture or a relatively longer slow leak. (a few hours) 

The others will have different symptoms. But it all boils down to asking what could be involved in that part of the body. By elimination, you will get to a vascular problem. You may not be able to definitively call it an aneurysm. But at that point it is until proven otherwise.


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## RocketMedic (Feb 13, 2013)

I see. So a cerebral aneurysm would = hemorrhagic stroke (which it is), thoracic could present as a hemothorax or something similar _or_ as something vague and nonspecific or anything in-between, an extremity aneurysm would present with localized deep bruising/swelling of the extremity (tourniquet?), and a AAA = emergent transport and palliative care with notification of chaplain and family?


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## Veneficus (Feb 13, 2013)

Rocketmedic40 said:


> I see. So a cerebral aneurysm would = hemorrhagic stroke (which it is), thoracic could present as a hemothorax or something similar _or_ as something vague and nonspecific or anything in-between, an extremity aneurysm would present with localized deep bruising/swelling of the extremity (tourniquet?), and a AAA = emergent transport and palliative care with notification of chaplain and family?



Sounds good.

Edit: You usually find limb aneurysms at the lower part of the pelvis and the knees. They were first described in carriage drivers and seem to continue today in people who sit for a long time or have repeated posterior knee trauma. (aptly named popliteal aneurysm)


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## mycrofft (Feb 13, 2013)

I tried to  find a "map" of referred aneurysm pain but no joy.

How about auscultation for bruit?


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