med 18

 

rysms should be referred for surveillance or elective

repair. Consider smoking cessation counseling, betablockers, antihyperlipid agents, and low-dose aspirin, as

appropriate.

CT or ultrasound

DISPOSITION

..... Admission

All patients with symptomatic AAAs should be admitted

for observation, further investigation, or surgery, in consultation with a vascular surgeon. If vascular surgery

consultation is not available, consider transfer. Both open

and endovascular outcomes are superior in centers that

perform a high volume of AAA repair. Ruptured AAA

mandates immediate surgery or endovascular repair if

the patient is to have any reasonable chance of survival.

..... Discharge

Patients with an asymptomatic AAA (i.e., incidental finding) and an alternate benign cause for their symptoms may

be discharged after follow-up with a vascular surgeon has

been arranged and appropriate risk factor modification

has been initiated.

SUGGESTED READING

Aggarwal S, Qamar A, Sharma V, et al. Abdominal aortic aneurysm:

A comprehensive review. Exp Clin Cardiol. 201 1;16: 1 1-15.

Lewiss RE, Egan DJ, Shreves A. Vascular abdominal emergencies.

Emerg Med Clin North Am. 201 1;29:253-272.

Metcalfe D, Holt PJE, Thompson MM. The management of

abdominal aortic aneurysms. BMJ. 20 1 1;342:d1 384.

Prince LA, Johnson GA. Aneurysms of the aorta and major

arteries. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 453-458.

Wittels K. Aortic emergencies. Emerg Med Clin North Am

20 1 1;29:789-800.

Gastrointestinal B leeding

jeffery A. Baker, MD

Key Points

• Aggressive resuscitative measures (intravenous access,

crystalloid bol us, and blood products) are necessary in

unstable patients with gastrointesti nal (GI) bleeding.

• A negative nasogastric lavage does not completely

exclude an upper Gl bleed.

• A brisk upper Gl bleed should be considered in the

differential of patients who present with hematochezia.