Key Points
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Vascular Hub Hospital: Frimley Park Hospital.
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Vascular Spoke Hospitals: Basingstoke and North Hampshire Hospital, Royal Surrey County Hospital, Wexham Park Hospital, Ashford and St. Peter’s Hospitals.
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Early Communication with all members of Multidisciplinary Team (Vascular, IR, ED-Resus, ICU, anaesthetics & Theatres) as soon as ruptured Aneurysm is suspected.
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Abbreviations
Clinical Signs & Symptoms
When to suspect possible ruptured aneurysm
History
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Patients with known history of AAA (aortic diameter >3cm)
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Family history (1st degree relatives) of abdominal aortic aneurysm
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Risk Factors: Ischemic heart disease, stroke, hypertension, smoking, dyslipidaemia
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Known connective disorder disease (e.g. Marfans, Elhers-Danlos syndrome)
Signs and symptoms (any of the following)
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Collapse
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Abdominal pain
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Abdominal pain radiating to the back
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Back pain
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Beware of the first diagnosis of renal colic in an elderly patient
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Abdominal expansile / pulsatile mass
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Hypovolemic shock: reduced GCS, hypotension, tachycardia (may be absent if patient on B-Blockers), reduced urine output.
If clinically suspected leaking Abdominal Aortic Aneurysm (AAA) identified at a Spoke Hospital, Emergency Department (at Spoke Hospital) to arrange the following
Initial management
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Immediate time critical transfer via 999 Ambulance to Frimley Park Hospital (FPH) ED
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If hemodynamically stable or unclear diagnosis patient should have urgent contrast CT aorta and on call vascular team alerted immediately.
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Acquire relevant history regarding co-morbidities, previous abdominal surgery, drug history, allergies and exercise tolerance (walking distance, day to day activity).
Factors which may strongly influence treatment /transfer include (On Call Vascular consultant to be made aware of these prior to transfer):
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Patient over the age of 75
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Cardiac arrest before transfer
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Intubated patient
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Significant co-morbidity:
i. MI in last 6 months
ii. Unstable angina
iii. Disabling CVA
iv. Disabling COPD (home oxygen)
v. CRF with creatinine > 180 µmol/l
vi. Cardiac arrest at any stage
vii. Loss of consciousness
viii. Advanced malignancy
ix. Dementia
x. Wheelchair existence
xi. Previous DNAR order
xii. Bed bound
The transfer process should only be initiated after discussion with the on call Vascular consultant. If the consultant is unavailable, discussion with vascular team must occur. The Vascular On-Call consultant must be informed of the potential transfer. It is the responsibility of the vascular team member (FPH) to escalate locally at FPH (eg IR / Anaesthetics / ICU / Theatre etc).
Treat as a surgical emergency
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If patient unconscious, any pre-existing DNACPR orders to be confirmed with family members.
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Call for help early - contact vascular registrar via switchboard - do not leave answer phone message but continue calling until response obtained. If not responding, contact Vascular On-Call Consultant via switchboard. The On-Call IR consultant should be alerted immediately following the call to the On-Call Vascular consultant.
Apply resuscitation principles
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Pain control with morphine and appropriate antiemetic
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High flow oxygen and airways maintenance (Contact On-Call Anesthetist if airways compromised).
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Intravenous access: 2x wide bore cannula.
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Allow Permissive Hypotension (Aim to maintain blood pressure > 70mmHg systolic. Aggressive fluid resus not required if systolic BP>70mmHg. Discuss fluid resuscitation with Vascular team).
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Send bloods: venous blood gas, FBC, U&E’s, clotting, amylase, lactate (do not delay transfer or discussions with FPH vascular team -results can be phoned through later after transfer).
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Send x 2 Group and screen and cross match blood (6 units).
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Request activation of massive blood transfusion protocol from blood bank.
Request packed cells, Fresh Frozen Plasma & platelets.
- Insert urinary catheter.
Do the following while waiting for the ambulance but do not delay transfer:
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Arrange for any images that have already been obtained, such as CT aorta, to be electronically transferred (IEP’d) to FPH.
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Transfer patient with spoke hospital identification wrist band, DOB, spoke hospital number & NHS number (if available).
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Document available blood results and send with patient or phone through to FPH if patient has already left.
You do NOT need to provide an escort.
Ask ambulance crew to pass a priority call to FPH ED when they are 10 mins out.
Vascular Team (FPH) Actions
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Alert On-Call Vascular Consultant and On-Call IR Consultant of transfer and again when patient in ED Resus.
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On-Call Vascular consultant to contact On-call IR consultant and discuss suitability for EVAR.
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Alert FPH ED Resus and provide details of transfer.
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If suitable for EVAR, On-Call IR consultant to contact Radiology staff (radiology nurses, radiographers).
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On site vascular team to check availability of necessary aortic stent grafts in IR dept after discussion with IR Consultant / Vascular Consultant.
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Contact On-Call anesthetic team / emergency theatre / ITU consultant if proceeding with intervention.
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Next of kin contact details to be documented to facilitate communication.
Contacts for referral: Please phone Vascular Service and FPH ED
How to use Hospital Bleep system:
Key in 1212 - listen to instructions - key in bleep no. - key in your extension no. - key in # - then listen to instructions and replace handset when instructed.
Full version control record
This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.
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