Hazards of Massage & The Lethal Rupture
Well another “jonah” call and a busy week!
Imagine this, on a quiet Sunday, I am on call. It was quiet till about 10pm, I get a call from my medical officer.
” A 60 year old man complained of left back pain around the loin. It was a sudden sharp continuous pain. He then told his son to massage his back. It helped a little. He said goodbye to his son who had to go for work. He went to toilet and thereafter asked his grand-daughter to massage him. As her massage was soft, he requested her to step on his back. This made his pain worse and he fainted and became unresponsive. He was brought in immediately and was initially confused but then collapsed and was resuscitated. Now, he is intubated with a heart rate of 100 and a blood pressure of 90/60 on two inotropes(drugs to maintain blood pressure).His abdomen is very distended, and he was very pale.”
With that, I made a diagnosis of ruptured Abdominal Aortic Aneurysm (AAA). We discussed with the family and they decided to give it a go for surgery.
What is an Aneurysm?
An aneurysm is when a blood vessel becomes abnormally large or balloons outward.
What causes an abdominal aortic aneurysm?
Atherosclerosis (also called hardening of the arteries).In atherosclerosis fatty deposits, called plaque, build up in an artery. Over time, this buildup causes the artery to narrow, stiffen and possibly weaken.
Risk factors that contribute to atherosclerosis, such as high blood pressure (hypertension). Besides atherosclerosis, other factors that can increase your risk of AAA include:
• Being a man older than 60 years
• Having an immediate relative, such as a mother or brother, who has had AAA
• Having high blood pressure
• Smoking
Risk of developing AAA increases as you age. AAA is more common in men than in women.
Signs & Symptoms
The symptoms of rupture include:
* Pulsating sensation in the abdomen
* Pain in the abdomen or back — severe, sudden, persistent, or constant. The pain may radiate to groin, buttocks, or legs.
* Abdominal rigidity
* Anxiety
* Nausea and vomiting
* Clammy skin
* Rapid heart rate when rising to a standing position
* Shock
* Abdominal mass
Findings from a few studies have suggested that most AAAs rupture into the left retroperitoneum. The retroperitoneum contains the leak by means of mechanisms that cause clotting or tamponade. This rupture can also cause abdominal, back, or flank pain; this symptom is related to impingement of the hematoma on adjacent structures.
Management
Surgery is recommended for patients with aneurysms bigger than 5.5 cm in diameter and aneurysms that rapidly increase in size. The goal is to perform surgery before complications or symptoms develop.
Prognosis
The outcome is usually good if an experienced surgeon repairs the aneurysm before it ruptures.
The mortality rate for ruptured AAA is substantial. As many as 2 of 3 patients with ruptured AAA die before arriving at the hospital. Of those who reach the hospital, as many as one fifth of those who die do so before the operation, and the overall mortality rate still averages approximately 49%.
January 31st, 2007 at 6:15 am
A sure way to get an Adrenaline rush is by finding out that there’s a leaking or ruptured AAA coming in for surgery whenever I’m on call. As difficult as it is for surgeons to operate on these, the anaesthetic management too is a huge challenge keeping you on your toes for the whole duration of the surgery. The new hospital I’m in doesn’t handle AAAs so I’m going to miss handling the GA side of these operations.
January 31st, 2007 at 6:28 am
Ya… get the message across:
DON’T massage these… even medical students were not allowed to examine the abdomen… remember the signboard at the foot of the bed? “No examination by medical students”
January 31st, 2007 at 5:48 pm
Yo I remember those signboards!
Shah I have to agree with you. This is also very challenging for the anaesthetist and it really depends on them once the bleeding is under control. How was the mortality rate in your previous hospital for emergency cases?
February 2nd, 2007 at 5:13 am
So what happened to the patient?
February 2nd, 2007 at 11:44 pm
I remember during my surgery posting last semester, we’re constantly told “be careful, make sure you’re really gentle!!!” while examining a patient with AAA. There was an incident though… when the patient concern had dementia and was really amused by the mass in his abdomen, he told us “look!! feel it!!! it moves!!!” We were so worried he’ll be the one rupturing it before his surgery that afternoon.
February 3rd, 2007 at 8:28 pm
Hi Shireen how are you? Oh! Little did I realise that I forgot to mention about the patient. There was an acute shortage of blood as the blod bank could only give us 6pints of blood. The anaesthetist had difficulty getting more blood and as a result they had to rush it from PDN. By the time we clamped the aorta and the iliacs, he failed to respond to fluid resuscitation, unlike the first case and unlike most of them. He was in irreversible shock. He was not bleeding blood anymore but all the colloids and crystalloids tainted with blood. Well after all that it would be a miracle for him to be alive. So have you started a blog? It will be fun to see how your life is there!
YP luckily he did try the “succussion splash” technique! or even better got one of those really blur students who felt that he or she had made an international discovery to knead it like dough. “Now you see it, yikes… Prof, the swelling has gone and…. , I think,….so has the patient!??!”