Case of the Month
February 2004

82-year-old male — abdominal/groin pain

After finishing a call at an adult living center you and your partner are directed to see an 82-year-old male complaining of abdominal pain and severe left testicular pain. You enter his room and find him sitting in the living room in a Barco lounger. He is conscious/alert and in apparent respiratory distress and unable to sit still. He alternates holding of his abdomen and groin area and states that his testicles hurt. His skin is pale, cool and sweaty. He appears in distress. You determine that he has a weak radial pulse at about 110 and at the same time you ask him if he has any other discomforts. He states that his “stomach and groin area” hurts. He has no other obvious complaints. Based upon these initial findings, obvious complaint and clinical picture, your initial assessment of this patient is…Sick!

You call for a medic unit and provide a patient status update. You further the assessment by calling for a set of vital signs and have the patient placed on high flow oxygen by NRM @ 12 Lpm. Vitals reveal a BP of 82/palp, pulse (radial) @ 110 slightly irregular and weak, respirations @ 24 with good tidal volume and bilateral breath sounds are heard (pulse oximetry reading @ 96%). The patient is conscious and alert, skin signs are pale, cool and moist. He is unable to sit still and therefore unable to get comfortable.

You prepare the patient for medic arrival expecting an ALS transport to the nearest and highest level hospital. You continue with your physical assessment including a SAMPLE history and detailed physical exam.

S	—	Signs/symptoms - abdominal/groin pain - pale, cool, moist skin
A	—	No known allergies
M	—	HCTZ for high BP, potassium, Lipator
P	—	High BP, history of smoking, diverticulitis
L	—	Breakfast about 1.5 hrs ago
E	—	Sudden onset of unrelenting abdominal/groin pain.

Medics arrive and complete your patient package with rapid IVs and transport to Harborview Medical Center. Later that night you receive a phone call from Medic 1 notifying you that your patient had died in the emergency department from exsanguination and secondary cardiac collapse resulting from a ruptured abdominal aortic aneurysm.

Abdominal Aortic Aneurysm (AAA)
Ruptured AAA is the 13th leading cause of death in the United States today. AAA results from the degeneration of one of the three interior linings of the aorta. Typically, the patient is a male and has a history of hypertension. The average age is in the 60’s to 80’s. Often the patient is asymptomatic until aortic expansion and rupture, causing profound clinical changes including: pain in the abdomen, groin, back and flank (isolated groin discomfort has been reported and must be considered a particularly worrisome presentation). Vital signs during rupture can include profound hypotension, tachycardia, and syncope and in 65% of the cases, death from exsanguination (bleeding out) and cardiac collapse prior to reaching a hospital and definitive care. In this particular case the patient’s appearance and vitals signs were the key that led you to believe that something very critical was going on.