Ruptured / Leaking Abdominal Aortic Aneurysm

Ruptured AAA has a prehospital mortality of ~50% and 30-day surgical mortality of 40%. The classic triad is sudden severe back/abdominal pain, pulsatile epigastric mass, and haemodynamic instability — but only 25–50% present with all three…

Vascular Society UK / NICE NG156

The pathway

1 · Recognise and activate vascular team immediately

Do NOT wait for imaging if the patient is haemodynamically unstable with suspected AAA
Call vascular surgery consultant directly — not via switchboard
Alert anaesthetics, theatre, and radiology simultaneously
Classic triad: sudden severe back/flank/abdominal pain + pulsatile mass + shock
In stable patients: bedside aortic USS for rapid confirmation (avoid CT delay in unstable)

2 · Permissive hypotension — key concept

Restrictive volume resuscitation (permissive hypotension) — NICE NG156 gives no numeric target. Aim for a patient who stays conscious and mentating, and follow the regional vascular protocol
Do NOT give large fluid boluses — raises BP → displaces tamponade → increases bleeding
Max 500ml crystalloid boluses only if losing consciousness
O-negative blood if cross-match unavailable and transfusion essential
No GTN, no antihypertensives
Move to theatre faster rather than normalise BP

3 · Bloods and MHP

Group and save / crossmatch 10 units PRBCs — immediately
Activate Major Haemorrhage Protocol (MHP): PRBCs : FFP : platelets in 1:1:1 ratio
FBC, coag, U&E, glucose, VBG, lactate
2 large-bore IV cannulae + arterial line (if time allows)
Tranexamic acid 1g IV over 10 minutes — give early

4 · CT aortogram — for haemodynamically stable patients only

If SBP >80 and haemodynamically stable → CT aortogram (chest-abdomen-pelvis with contrast)
Provides: confirmation of rupture, anatomy for EVAR planning, assessment of iliac vessels
Do NOT take unstable patient to CT — direct to theatre
Brief the CT radiologist: urgent aneurysm query, potential EVAR

5 · EVAR vs Open Repair decision

EVAR (Endovascular Aneurysm Repair): preferred if anatomy suitable (infrarenal neck ≥15mm, adequate iliac access)
Lower 30-day mortality than open, faster, less blood loss
Not available at all centres — transfer if needed (only if stable)
Open repair: if anatomy unsuitable for EVAR, EVAR equipment/expertise unavailable, or juxta/suprarenal rupture
Retroperitoneal approach: preferred for ruptured AAA (better proximal control)
Decision: vascular surgeon + vascular interventional radiologist

6 · Intraoperative and post-operative care

Aortic cross-clamp → immediate haemostasis in open repair
Hypothermia: warm IV fluids, warming blanket, warm theatre
Lethal triad: hypothermia + coagulopathy + acidosis — aggressive correction
Post-op ITU: organ support, bowel ischaemia surveillance (elevated lactate, bloody NG), AKI very common
Endoleak surveillance post-EVAR: CT at 1 month, then 1 year

Drugs

Drug	Dose	Route	Notes
Tranexamic acid	1g IV over 10 minutes	IV	Give early in suspected haemorrhage. Second dose 1g IV at 3 hours if ongoing bleeding.
O-negative PRBCs	2–4 units	IV	Uncrossmatched blood if actively dying before crossmatch available. Switch to crossmatched blood ASAP.
FFP (Fresh Frozen Plasma)	4 units per 4 units PRBC	IV	1:1:1 ratio with PRBCs and platelets via MHP. Corrects coagulopathy.
Cryoprecipitate	2 pools (10 units)	IV	If fibrinogen <1.5 g/L (target >1.5 g/L). Activated via MHP.
Calcium gluconate 10%	10–20ml IV	IV	Massive transfusion chelates calcium — replace every 4 units of blood products.
0.9% NaCl	500ml bolus (cautious)	IV	Minimal fluid pre-operatively — restrictive resuscitation, titrated to consciousness rather than to a number. NICE NG156 sets no target SBP. Avoid large-volume resuscitation.

When to escalate

SBP <50 or GCS falling — immediate theatre regardless of imaging, open aortic cross-clamp,Anatomy unsuitable for EVAR at local centre and patient stable enough — emergency transfer to EVAR-capable vascular centre,Post-op rising lactate or bloody NG — bowel ischaemia; emergency laparotomy and bowel viability assessment,Post-op AKI — renal replacement therapy via ITU; contrast-induced + hypoperfusion injury,Endoleak post-EVAR (early) — interventional radiology for embolisation or secondary procedure,Haemodynamic collapse on table — consider aortic balloon occlusion (REBOA) if available as bridge

Reference: Vascular Society UK Ruptured AAA Guidelines / NICE NG156 Abdominal Aortic Aneurysm 2020

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.