Don’t overlook signs of life-threatening aneurysm
The statistics are chilling: 50% of abdominal aortic aneurysm (AAA) patients die before reaching the ED, and perioperative mortality for patients who do reach the ED ranges from 50%-90%.1
To prevent missing an aneurysm, you must know the signs and symptoms to watch for, says Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, clinical educator for the ED at Children’s Memorial Hospital and formerly clinical educator for the ED at Northwestern Memorial Hospital, both based in Chicago.
"Take the time to obtain a thorough history, a systematic pain assessment, and a detailed physical exam," she advises.
A recent wrongful death lawsuit filed by the family of the late TV sitcom star John Ritter puts a spotlight on the liability risks associated with a missed aortic aneurysm, based on the claim that a misdiagnosis of a heart attack contributed to his death.
"The majority of abdominal aortic aneurysms are asymptomatic and present only when they begin to leak or rupture," notes Debra Graf, RN, BSN, CEN, director of patient care for Quick Care/Kid Care at the ED at Community Medical Center in Toms River, NJ, and former ED educator. Symptoms to watch for include the following, she says:
- The patient or family often reports a syncopal episode prior to the onset of other symptoms.
- Hypotension may stabilize temporarily.
- The patient will have tachycardia and excruciating back or abdominal pain that may radiate to the groin or legs.
- Other symptoms include pallor, diaphoresis, oliguria, mottling of the lower extremities or abdomen, umbilical or flank ecchymosis, abdominal tenderness or rigidity, diminished bowel sounds, and diminished or absent femoral pulses. "Only 25% of these patients will have a palpable pulsatile mass," Graf says.
ED nurses should suspect AAA in any patient older than age 60 with low back pain and a history of smoking, hypertension, diabetes, or hyperlipidemia, she notes. "It is five to seven times more prevalent in males than females," she adds. "So if a 70-year-old male arrives with complaints of a syncopal episode and low back pain, we assume AAA until our work-up proves otherwise."
The gold standard test for AAA is a computed tomography (CT) scan, but the work-up also will include a complete blood count, chemistry, type and screen, cardiac markers, amylase, lipase, chest X-ray, electrocardiogram (ECG), and urine analysis, says Graf. "Since the worst-case scenario is a ruptured AAA, which is fatal, there is no risk of mistaking an AAA for other conditions," she says. "The risk occurs when the patient is treated for cholecystitis or something else when actually there is a leaking aorta that is going to kill the patient."
Abdominal or thoracic aneurysm?
A patient’s signs and symptoms depend on where in the aorta the aneurysm is located, says Steinmann. "Eighty percent of aortic aneurysms occur in the abdominal region," she notes.
AAAs are characterized by severe back pain, accompanied by abdominal pain and tenderness with palpation, says Steinmann. "The back pain may radiate to the legs, groin, or lower back. A widened midline pulsation proximal to the umbilicus may be noted on physical exam." Abdominal aneurysms often are diagnosed with ultrasound or CT scans, she adds.
Most abdominal aortic aneurysms occur in 50- to 70-year-olds, and the primary etiology is atherosclerosis and related factors — so a history of hypertension, hyperlipidemia, and diabetes increases the risk, says Steinmann. "Be aware of younger adults, though, with a history of hereditary connective tissue disorders such as Marfan’s syndrome or Type IV Ehlers-Dano, as these disorders increase the risk for aortic root dilatation and subsequent dissection or rupture."
In thoracic aneurysms, patients generally report excruciating intrascapular pain or a ripping sensation within the chest, and they may experience hoarseness and difficulty swallowing, says Steinmann. "A pulsation may be apparent at the sternoclavicular joint, and a murmur of aortic insufficiency may be noted if the thoracic aorta dissects down to the level of the aortic valve," she says.
Patients with thoracic dissections present with cardiac ischemia noted as ST elevation on the ECG if the area of dissection involves the coronary arteries, says Steinmann. "It’s critical to differentiate the cause of the ischemia, as administering fibrinolytics agents to the patient with a dissecting thoracic aneurysm may exacerbate the dissection," she says.
Prior to rupture or dissection, patients with enlarging thoracic aneurysms may note pain in the upper back, coughs and wheezes, a hoarse voice, difficulty with swallowing, and Horner’s syndrome with symptoms of drooping eyelid, constricted pupil, and dry skin on one side of the face from the expanding aorta exerting pressure on surrounding organs in the chest, says Steinmann.
Thoracic aortic aneurysms are most commonly diagnosed on chest X-ray with evidence of a widened mediastinum, says Steinmann. "CT scans and magnetic resonance imaging may also be helpful in making a differential diagnosis," she says.
1. Naude GP, Bongard FS, Demetriades D. Trauma Secrets. Philadelphia: Hanley & Belfus; 1999.
For more information on improving care of patients with aortic aneurysm, contact:
- Debra Graf, RN, BSN, CEN, Director, Patient Care for Quick Care/Kid Care, Emergency Department, Community Medical Center, 99 Route 37 W., Toms River, NJ 08755. Telephone: (732) 557-2759. Fax: (732) 557-2124. E-mail: DGraf@sbhcs.com.
- Rebecca Steinmann, RN, MS, CEN, CCRN, CCNS, Clinical Educator, Emergency Department, Children’s Memorial Hospital, Box No. 66, 2300 Children’s Plaza, Chicago, IL 60614-3394. Telephone: (773) 975-8764. Fax: (773) 880-3429. E-mail: RSteinmann@childrensmemorial.org.