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Suspected ruptured abdominal aortic aneurysm — MRCEM SBA MCQ

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HardCardiovascular emergenciesSuspected ruptured abdominal aortic aneurysmMRCEM SBA

A 73-year-old man attends a district general hospital after sudden severe back pain and a brief collapse. He is alert and answering questions, but pale and clammy. His blood pressure is 84/52 mmHg and pulse 118/min; his systolic pressure rose briefly to 96 mmHg after 250 mL intravenous crystalloid, then fell again. Bedside ultrasound shows a 7.2 cm abdominal aortic aneurysm but no free intraperitoneal fluid. Monitoring, intravenous access and analgesia are in place. The regional vascular service has accepted him immediately. Local CT angiography could begin in 25 minutes, whereas an ambulance is ready to depart now. Which management and disposition plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Transfer immediately for vascular assessment; use restrictive volume resuscitation.

Sudden back pain, collapse, recurrent hypotension and a large aneurysm make rupture the working diagnosis. Bedside ultrasound identifies the aneurysm; the absence of visible free fluid does not exclude rupture. ([nice.org.uk](https://www.nice.org.uk/guidance/ng156/chapter/Recommendations)) NICE recommends immediate discussion with a regional vascular service when ultrasound shows an aneurysm and departure within 30 minutes once emergency transfer is agreed. It advises considering restrictive volume resuscitation during transfer. ([nice.org.uk](https://www.nice.org.uk/guidance/ng156/chapter/Recommendations)) **E** therefore prioritises definitive vascular assessment without delaying departure. **A** is attractive because CT angiography helps assess suspected rupture and plan repair, but waiting for a local scan delays this already-accepted, hypotensive patient; NICE recognises that some patients need transfer without first having CT. ([nice.org.uk](https://www.nice.org.uk/guidance/ng156/chapter/Rationale-and-impact)) **B** transfers promptly but attempts to normalise blood pressure rather than using the recommended restrictive approach. **C** delays transfer for a repeat test that cannot reliably establish or exclude rupture. **D** delays transfer to assess a fluid response despite recurrent hypotension and an available receiving service. Resuscitation must continue to support perfusion, but neither further imaging nor a normal blood pressure is a prerequisite for departure. ([nice.org.uk](https://www.nice.org.uk/guidance/ng156/chapter/Recommendations))

Reference: NICE NG156: Abdominal aortic aneurysm: diagnosis and management — Recommendations (19 March 2020) — https://www.nice.org.uk/guidance/ng156/chapter/Recommendations NICE NG156: Rationale and impact — Imaging technique (19 March 2020) — https://www.nice.org.uk/guidance/ng156/chapter/Rationale-and-impact Accuracy of presenting symptoms, physical examination, and imaging for diagnosis of ruptured abdominal aortic aneurysm: systematic review and meta-analysis (2022) — https://pubmed.ncbi.nlm.nih.gov/35220634/