PE, tamponade and aortic emergencies

Ruptured abdominal aortic aneurysm

Reviewed Nov 2026·1 references
New· views rounded down, updated weekly

Rapid recognition, permissive hypotension, massive transfusion and immediate transfer for EVAR or open repair.

Definition
Ruptured AAA = haemorrhage from an abdominal aortic aneurysm (usually > 5.5 cm, but rupture occurs at smaller sizes). Classic triad: abdominal/back/flank pain, hypotension, pulsatile mass (present in < 50%).

At the bedside

Timed steps
  1. 1

    Suspect

    0 min

    Older man (> 60), smoker, hypertensive, with sudden abdominal/back/flank pain and collapse or hypotension. Often misdiagnosed as renal colic, MI or pancreatitis.

  2. 2

    Bedside ultrasound

    < 5 min

    Aortic diameter > 3 cm confirms aneurysm; in an unstable patient with known/likely AAA, this plus the clinical picture is enough to call the vascular team.

  3. 3

    Permissive hypotension

    Keep the patient conscious with SBP ~70-90 mmHg; avoid large crystalloid volumes; give blood products in ratio (activate MTP), TXA per local policy.

  4. 4

    Image only if stable

    CT angiography to plan EVAR in haemodynamically stable patients; unstable patients go straight to theatre/hybrid suite.

  5. 5

    Transfer immediately

    Contact the nearest vascular centre at once; EVAR is preferred when anatomically suitable. Do not delay transfer for further tests.

  6. 6

    Post-op ICU

    Watch for abdominal compartment syndrome (measure bladder pressure), colonic ischaemia (bloody diarrhoea, lactate), AKI, limb ischaemia, coagulopathy.

Haemorrhagic shock

Packed red blood cells (PRBC) with plasma and platelets

IV (warmed)
Dose
Activate MTP: PRBC:FFP:platelets 1:1:1
Target
Conscious patient, SBP ~70-90 mmHg until aortic control
Red flag · call your senior now
'Renal colic' in a man over 60 with hypotension: scan the aorta.
Red flag
Rising bladder pressure > 20 mmHg with new organ dysfunction after repair = abdominal compartment syndrome.
Pitfall
Aggressive fluid resuscitation to 'normal' BP: dislodges clot and increases bleeding.
Pitfall
Waiting for CT in an unstable patient.
Pearl
Ultrasound measures outer wall to outer wall in the transverse plane; bowel gas can obscure the view - scan from the left flank.

References

  1. 1

    Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024;67:192-331.

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Acute aortic dissection: BP and HR targets

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