66 year old gentleman presents to A&E following a collapse, his wife is with him. She explains that they were at a wedding when her husband complained of feeling dizzy and then fell to the floor, he has been unresponsive since then. She tells you that her husband is generally fit and well but does mention that he has been a life long smoker. On general examination he is pale and has a fast, thready pulse and his blood pressure is unrecordable on the automatic machine. He is unable to answer any of your questions and is clutching at his abdomen in severe pain.

What is the best course of action? 

A) Analgesia to facilitate a better history.

B) Refer to surgeons for emergency surgery.

C) Perform an ECG.

D) Obtain abdominal US scan. 

E) Perform abdominal examination.

The answer is B, this gentleman has the clinical signs of ruptured abdominal aortic aneurysm and urgently requires surgery. The classic triad of ruptured abdominal aortic aneurysm is hypotension, abdominal/back pain and pulsatile abdominal mass. 

A ruptured AAA can mimic renal colic, testicular pain, diverticulitis, bowel ischemia and acute pancreatitis. 

US and CT play a role in the screening of AAA but at this stage getting this gentleman to the operating theatre is more important. 

Smoking is the most strongly related risk factor to developing AAA, each year spent smoking increases relative risk of developing AAA by 4%.