In general, I am a big fan of management discussion, always lively! I do appreciate the exercise because only when questioned does one truly gain an understanding of the topic. Coleman, 2002.
On that note, in regards to Docxter's comments:
The facts of patients with AAA:
autopsy of patients 50 and older: 2-4% w/AAA*
men aged 65 and older: 5-10% w/AAA*
*Rosens 5th ed. page 1177, Table 81-1
so we can conclude that not all people over 70 have some degree of AAA, in fact, very few do.
Docxter said:
all people above 70 coming through the door have some degree of AAA. If they have happen to have abd. pain +/- hypotension, would you send all of them to the OR for an emergent AAA repair just by doing an ultrasound and seeing a AAA on US? The vascular surgeons will not be happy!!!
So, a 72 year-old female presents to the ED w/abdominal pain, bp of 70/40 and U/S reveals a AAA and you are not going to contact vascular?
Rosen: page 1183
In symptomatic patients (abdominal or flank pain w/hypotension):
If an AAA can be diagnosed with bedside testing (US) the surgeon will often proceed immediately to the OR with a clinical diagnosis of aneurysm rupture, because a delay in surgery places the patient with a ruptured AAA at risk for sudden and unpredictable hemodynamic deterioration
Surgical mortality in patients with ruptured AAAs is approximately 50% and has shown little improvement in the past two decades.
Hypotension is the most important factor predicting a poor outcome; a low initial hematocrit also increases the likelihood of perioperative death.
When patients who do not reach the OR are considered, the overall mortality rate is 80% to 90%
Docxter, given all this information, I would argue that the standard of care in symptomatic hypotensive patients with a AAA on bedside U/S, whether new or old, warrants IMMMEDIATE consultation and likely surgery, and the need for CT is questionable depending on your vascular surgeon.
For those interested in more reading, check out:
Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years.
Acad Emerg Med. 2003 Aug;10(8):867-71.