Ruptured Abdominal Aortic Aneurysm discovered by Pocket-sized ultrasound in low resource settings: A case report

doi:10.21203/rs.3.rs-3213354/v1

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Case Report

Ruptured Abdominal Aortic Aneurysm discovered by Pocket-sized ultrasound in low resource settings: A case report

https://doi.org/10.21203/rs.3.rs-3213354/v1

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Journal Publication

published 17 Jan, 2024

Read the published version in International Journal of Emergency Medicine →

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Introduction:

While AAA is a life-threatening condition that manifests suddenly in the Emergency department less is known about the use of hand-held ultrasound to diagnose it, especially in low-resource settings.

Case presentation:

A 78-year old man whose a known case of hypertension, the family reported he complained of severe loin pain then he collapsed at home, upon arrival to the ED patient was unconscious with unrecordable BP, pulses were intact, rapid sequence intubation (RSI) was done, ECG showed no ischemic changes, a few seconds later the patient becomes pulseless 1 cycle of CPR was done and the patient reverted to sinus rhythm then he was started on noradrenaline immediately, a few minutes later the lower limbs were noted to be paler and colder than upper limbs raising the suspicion of ruptured AAA, point of care US was done using hand-held ultrasound connected to a tablet, the ultrasound showed a ruptured AAA around 8 cm with intimal flap, surgical intervention was not available because of vascular surgery unavailability at that time, the patient becomes pulseless again CPR was initiated with no response despite the blood-transfusion, finally death was announced.

Discussion and conclusion:

Ruptured AAA is considered a vascular surgical emergency with a very high mortality rates, this case report highlights the importance of POCUS in emergency departments especially the cheaper models of hand-held ultrasound probes.

POCUS

Pocket-sized Ultrasound

Ruptured abdominal aortic aneurism

Abdominal aortic aneurysm (AAA) is a potentially life-threatening condition characterized by weakening and dilation of more than 3cm of the abdominal aorta [1, 2]. It affects men and smokers more commonly and its prevalence increases with age [3, 4]. While AAA can develop asymptomatically, it can also manifest as sudden and severe pain in the abdomen, back, or flank, often requiring urgent medical intervention. Delay in diagnosis and treatment contribute to the high mortality of the disease with rupture being the most fatal complication [5, 6, 7]. In acute settings of suspected AAA, point-of-care ultrasound can be used with high accuracy [8]. However, less is known about the use of ultrasound to diagnose AAA rupture. We report a case of a ruptured AAA identified by pocket-sized ultrasound in the emergency department (ED).

A 78-year old man presented to the Emergency Department on 14th of February 2023 at 9 pm complaining of suprapubic pain that started earlier in the morning and became progressively worse, pain was not radiating anywhere, and was associated with frequency, with no other lower urinary tract symptoms, fever or chills. Triage assessment was level 4 semi-urgent. His medical history was remarkable for hypertension, benign prostatic hyperplasia, and a history of low-grade bladder ca diagnosed in 2013.

His GCS was 15, Blood pressure was 124/60, pulse was 77/min, respiratory rate was 20/min, oxygen saturation was 98% on room air, and temperature was 37°C. The patient was conscious, alert, and oriented to place, time, and person. His abdominal examination revealed a soft lax abdomen without tenderness and no costovertebral angle tenderness. CBC, KFT, urine analysis, and culture were done, and all were normal except for slight anemia with a hemoglobin level of 12.9 g/dL and slight hypokalemia with a value of 3.34 mmol/L (results are presented in Table 1). The patient was given IV Paracetamol, IV Hyoscine butyl bromide, IM diclofenac, and normal saline. He was then referred to a urology clinic and discharged.

Table 1,” a table showing the blood work results for the patient in both visits.”

Date	14/2/2023	15/2/2023
Test	results	results
RBS	122	89.1
Na	130.5	145.3
K	3.34	3.47
Urea	22.1	12.5
Creatinine	0.615	0.900
CL	________________	109.6
Calcium	________________	6.96
Phosphorus	________________	5.01
Mg	________________	2.51
CK-MB	________________	15.7
CPK	________________	103
Urine analysis	COLOUR: pale yellow Transparency: clear Reaction: Neutral Protein: nill Sugar: nill WBC/HPF: 1-2 RBC/HBF: 2-4 Ep. Cells: 1-2 Bacteria: seen Others: mucus	________________
URIN	RESULT: NO BACTERIAL GROWTH
B-Type NPP	________________	176.83
HS TROPONIN E1	________________	64.14
CBC	Hb&Ht:12.9/39.7 WBC:7.61 MCV:83.1 MCH:27.0 RBC:4.78 MCHC:32.5 RDW:15.8 Neutrophils %: 76.7 Eosinophil %:0.2 Basophils %:0.2 Lymphocyte %:16 Monocyte %:6.4 Platelets count:235 MPV:9.1	Hb&Ht:10.2/32.6 WBC:5.76 MCV:86.3 MCH:27.1 RBC:3.77 MCHC:31.4 RDW:15.9 Neutrophils %: 61.6 Eosinophil %:0.1 Basophils%:0.4 Lymphocyte %:34.0 Monocyte %:3.9 Platelets count:165 MPV:9.5
CRP	________________	46.3

On the next day 15th of February 2023, the patient had severe loin pain in the morning, then suddenly collapsed and lost consciousness as reported by his family. He was then transferred to the ER by ambulance. In the ER the patient was unconscious with GCS of 6/15 (E4 V1 M1), both Bp and O2 sat were not recordable, pulse was intact, and pupils were both mid-dilated with sluggish reactivity to light. Intubation with rapid sequence induction was performed. Post-intubation electrocardiogram demonstrated normal sinus rhythm without acute ST changes. A few seconds later the patient became pulseless, 1 cycle of CPR was done with 1 mg of adrenaline, sodium bicarb, and calcium gluconate were given. After that, the patient reverted and was started on Noradrenaline at a maximum dose with BP recorded at 80/50. Labs were sent for crossmatch, CBC, CRP, KFT, electrolytes, Troponin, and BNP.

Four minutes later he was arrested again, another 1 CPR cycle with adrenaline was done and the patient reverted again. Post-CPR electrocardiogram again demonstrated normal sinus rhythm without acute ST changes and the results of venous blood gas on the ventilator were: PH = 7.295/ pCO2 = 23.9/ cHCO3 = 11.4/ ctCO2 = 12.1/ BE = -13 / pO2 = 138/ SO2 = 98%. During that we noticed that his lower limbs were paler and colder than his upper limbs, thus carotid and femoral pulses were examined, and the examination showed a diminished femoral pulse when compared to the carotid pulse. Point of care ultrasound was done using the "Butterfly IQ ultrasound probe", which is a portable pocket-sized probe that can be easily connected to a phone or a tablet (image shown in Fig. 1), and found ruptured dissecting AAA around 8 cm with an intimal flap. Despite starting a massive blood transfusion and giving 1 gram of tranexamic acid, the Vascular surgery team was not available until about one hour later, while they evaluated the patient in ED, his condition was extremely unstable. During that, laboratory results were out, and hemoglobin level dropped from 12.9 g/dL to 10.2 g/dL within a day, PO₄ = 5, troponin = 64 (All results are presented in Table1). The patient was arrested again, and 8 cycles of CPR were done with adrenaline 1 mg given 4 times, the patient had pulseless electrical activity during the whole resuscitation process with the unavailability of REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) kits, unfortunately, the patient died despite all the resuscitation efforts, and death was announced at 11:37 AM.

Abdominal aortic aneurysm is the focal dilation of the abdominal aorta of more than 3 cm in ultrasound or CT imaging [2]. It most commonly occurs among patients above the age of 65. Moreover, a meta-analysis conducted in 2013 showed that its prevalence is 6% in men and 1.6% in women [11]. One of the risk factors includes smoking; being the most important risk factor for AAA with a prevalence of 1 in 9 for current smokers compared to 1 in 17 in the general population [4]. Male sex, advanced age, atherosclerosis, hypertension, Hypercholesterolemia, positive family history and trauma are all other risk factors for the disease [9]. The diameter of the abdominal aorta is the best predictor factor for the risk of rupture, being almost nonexistent when the diameter is less than 4. However, the risk increases with the increase of the diameter, reaching 30–50% when it reaches 8 cm [10].

Ruptured abdominal aortic aneurysm is considered a vascular surgical emergency, in which unfortunately 50% of patients die even before reaching the hospital, with an overall mortality rate reaching up to 80–90% [12]. Most AAAs are asymptomatic until they rupture [13]. This highlights the importance of screening those with risk factors. The USPSTF recommends 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have never smoked. An abdominal aortic aneurysm can be diagnosed using ultrasound. In a systemic review conducted by Elizabeth Rubano, the Sensitivity and specificity of the ED US for the detection of AAA were reported to be 99% and 98% respectively [14]. However, it is much less useful in identifying rupture since 88% of AAAs rupture into the retroperitoneal space, where ultrasound visualization is limited [15]. Thus, Computed tomography is still considered the diagnostic modality of choice for ruptured AAA. However, because it’s less available, time-consuming, and usually needs the patient to be transferred out of the ED, the use and importance of point-of-care ultrasound (POCUS) has increased more and more.

In conclusion, our case highlights the importance of excluding AAA in those with risk factors complaining of any abdominal pain, this can be easily done using a hand-held Ultrasound probe. Unfortunately, in the case reported here, the patient’s AAA remained undiagnosed until he presented to the ED with ruptured AAA despite his presentation the day before complaining of suprapubic pain. A screening Ultrasound in his first presentation even with low-cost probes, would likely have identified his AAA before rupture and allowed him to be evaluated for surgical repair. In conclusion, ultrasound must be available in all emergency departments, and all emergency physicians must inquire about the skills needed to use it proficiently.

AAA

Abdominal Aortic Aneurysm

RSI

Rapid sequence intubation

Ultrasound

POCUS

Point of Care Ultrasonography

GCS

Glasgow Coma Scale

USPSTF

United States Preventive Services Task Force

Ethical approval

This study was approved by “Jordan university Institutional review board (IRB), and

This study was performed in accordance with the ethical standards as laid down in the 1964

Declaration of Helsinki and Belmont report.

Consent to participate.

A written informed consent was obtained from all participants for participation.

Consent to publication.

A written informed consent was obtained from the patient legal guardian for the publication of this study and accompanying images.

Availability of data and material

All data generated or analyzed during this study are included in this published article.

Competing interests.

The authors declare that they have no competing interests.

Funding

This study required no funding.

Authors’ contributions:

BH and RS worked together in making the table of laboratory results and sorting out the data and organizing it from the electronic patient system. RA wrote the abstract and had an important role in editing the manuscript. IA took a written consent from the patient legal guardian and edited the manuscript writing with the supervision of the teamwork.

Acknowledgements.

Not applicable

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No competing interests reported.

Download PDF

Journal Publication

published 17 Jan, 2024

Read the published version in International Journal of Emergency Medicine →

Editorial decision: Major revision
18 Sep, 2023
Reviews received at journal
09 Sep, 2023
Reviewers agreed at journal
08 Sep, 2023
Reviewers invited by journal
08 Sep, 2023
Submission checks completed at journal
04 Aug, 2023
Editor assigned by journal
04 Aug, 2023
First submitted to journal
28 Jul, 2023

You are reading this latest preprint version

Ruptured Abdominal Aortic Aneurysm discovered by Pocket-sized ultrasound in low resource settings: A case report

Status:

Journal Publication

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Abstract

Introduction:

Case presentation:

Discussion and conclusion:

Figures

Introduction

Case presentation

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1