What are the initial management orders for a patient admitted with an aortic aneurysm?

Initial Management Orders for Aortic Aneurysm Admission

All patients admitted with suspected or confirmed aortic aneurysm—particularly acute aortic syndromes—require immediate ICU admission with invasive arterial blood pressure monitoring and aggressive anti-impulse therapy to reduce aortic wall stress and prevent rupture or dissection. 1

Immediate Monitoring and Access

• Establish invasive arterial line monitoring (preferably right radial artery) for continuous blood pressure measurement 1
• Continuous three-lead ECG monitoring to detect ischemia 1
• Place two large-bore IV lines—one for medications, one for potential fluid resuscitation 1
• Transfer to ICU immediately upon admission 1

The arterial line is critical because non-invasive measurements may be unreliable if branch vessels are compromised, and beat-to-beat monitoring allows precise titration of anti-impulse therapy 1.

Laboratory Studies

Order the following blood work immediately upon admission 1:

• Cardiac biomarkers: CK, troponin T/I, myoglobin (to assess for myocardial ischemia from coronary involvement)
• Complete blood count with differential (leukocytosis may indicate inflammation or rupture)
• Lactate dehydrogenase (LDH) and hematocrit (elevated LDH suggests visceral ischemia; falling hematocrit suggests bleeding)
• D-dimer (elevated in acute aortic syndromes)
• Type and crossmatch for potential surgical intervention
• Basic metabolic panel to assess renal function and electrolytes

Hemodynamic Management

Blood Pressure Control

Target systolic blood pressure <120 mmHg (or lowest BP that maintains adequate end-organ perfusion) 1:

• First-line: IV beta-blockers (propranolol, metoprolol, esmolol, or labetalol) to reduce both blood pressure and heart rate 1
• Target heart rate: 60-80 bpm to minimize aortic wall stress 1
• Add IV vasodilators (sodium nitroprusside) if BP remains elevated despite beta-blockade, titrating to systolic BP 100-120 mmHg 1

Critical pitfall: Never give vasodilators before beta-blockade, as unopposed vasodilation increases shear stress (dP/dt) on the aortic wall and can precipitate rupture or dissection extension 1.

Alternative Agents

• For patients with contraindications to beta-blockers (severe COPD, asthma, heart block): Use IV non-dihydropyridine calcium channel blockers (diltiazem or verapamil) for rate and pressure control 1

Pain Management

• Administer IV morphine sulfate for pain relief 1
• Adequate analgesia is essential not only for patient comfort but also to reduce sympathetic surge that elevates blood pressure and heart rate 1

Diagnostic Imaging

Initial Imaging

• Obtain 12-lead ECG immediately to document ischemia or infarction 1
• Transthoracic echocardiography (TTE) as initial bedside imaging to assess aortic valve function, pericardial effusion, and proximal aorta 1

Definitive Imaging

Order CT angiography (CTA) of the chest/abdomen/pelvis as the primary diagnostic modality for most patients 1:

• CTA provides rapid, comprehensive assessment of aneurysm size, location, and complications
• If CTA is contraindicated (contrast allergy, renal failure), consider cardiovascular MRI (CMR) 1
• Transesophageal echocardiography (TEE) can be performed at bedside in unstable patients or intraoperatively 1

Chest X-ray may show widened mediastinum (abnormal in 60-90% of dissections) but should be omitted in unstable patients to avoid treatment delays 1.

Physical Examination Priorities

Document the following findings that indicate complications 1:

• Pulse deficits in all four extremities (present in up to 20% of proximal dissections)
• Blood pressure differential >20 mmHg between arms (suggests arch vessel involvement)
• Diastolic murmur at left sternal border (aortic regurgitation in ~50% of proximal dissections)
• Neurological deficits (altered consciousness, focal weakness—occurs in up to 40%)
• Signs of cardiac tamponade (muffled heart sounds, elevated JVP, hypotension)

Surgical Consultation

• Immediate cardiothoracic surgery consultation for all acute aortic syndromes and symptomatic aneurysms 1
• Vascular surgery consultation for descending thoracic or abdominal aortic aneurysms 1

Additional Considerations

• NPO status in anticipation of potential emergency surgery
• Avoid thrombolysis if acute coronary syndrome is suspected until aortic pathology is ruled out by imaging 1
• Assess for genetic syndromes (Marfan, Loeys-Dietz, Ehlers-Danlos, bicuspid aortic valve) which lower surgical thresholds 1, 2

The most common pitfall is delaying anti-impulse therapy while awaiting imaging—medical management should begin immediately based on clinical suspicion, as mortality increases with every hour of uncontrolled hypertension and tachycardia 1.