A patient presents with fever and a new pulsatile abdominal mass consistent with suspected ruptured abdominal aortic aneurysm. What is the immediate management?

• A. Emergent resuscitation and surgical evaluation; maintain perfusion, avoid palpation if rupture suspected.
• B. Immediate CT angiography to confirm diagnosis
• C. Start broad-spectrum antibiotics only
• D. Immediate laparotomy without resuscitation

Answer: (A)

In suspected ruptured abdominal aortic aneurysm, time is everything: the priority is to stabilize the patient and move quickly to definitive surgical control of the bleed. Emergent resuscitation to maintain adequate perfusion, along with rapid surgical evaluation, is the best initial approach. Avoiding abdominal palpation helps limit further manipulation and potential worsenings of the rupture while you prepare for surgery.

Start with securing the airway if needed, establish two large-bore IV lines, type and crossmatch blood, and begin aggressive but pragmatic resuscitation to preserve perfusion without delaying definitive control. Then arrange urgent surgical management—either open repair or endovascular repair depending on local resources and patient status.

Imaging with CT angiography would delay treatment in a hemodynamically unstable patient and isn’t the immediate step here. Starting broad-spectrum antibiotics alone does not address the ruptured aneurysm. Proceeding to laparotomy without resuscitation would risk worsening shock and poor outcomes.