Initial Admission Orders for Aortic Aneurysm
Immediately admit the patient to the ICU with invasive arterial blood pressure monitoring and initiate aggressive anti-impulse therapy to reduce aortic wall stress and prevent rupture or dissection. 1
Immediate Monitoring and Vascular Access
- Place an invasive arterial line in the right radial artery for continuous blood pressure measurement to guide aggressive hemodynamic management 1
- Establish continuous three-lead ECG monitoring to detect myocardial ischemia from potential coronary involvement 1
- Insert two large-bore IV lines—one dedicated to vasoactive medications and one for potential fluid resuscitation 1
- Transfer directly to ICU upon admission without delay 1
Laboratory Orders
- Cardiac biomarkers (troponin T/I, CK, myoglobin) to assess for myocardial ischemia from coronary artery involvement 1
- Complete blood count with differential to detect leukocytosis suggesting inflammation or rupture 1
- Lactate dehydrogenase (LDH) and serial hematocrit measurements—elevated LDH indicates visceral ischemia and declining hematocrit suggests active bleeding 1
- D-dimer level, which is typically elevated in acute aortic syndromes 1
- Type and crossmatch for at least 4-6 units of packed red blood cells in preparation for potential surgical intervention 1
Hemodynamic Management Protocol
Target systolic blood pressure <120 mmHg (or the lowest pressure maintaining adequate end-organ perfusion) and heart rate 60-80 bpm to minimize aortic wall stress. 1
- First-line: IV beta-blockers (esmolol, labetalol, metoprolol, or propranolol) to simultaneously reduce blood pressure and heart rate 1
- Esmolol is preferred for its short half-life and titratable properties in the acute setting
- Target heart rate 60-80 bpm before adding additional agents 1
- Second-line: IV sodium nitroprusside if blood pressure remains >120 mmHg despite adequate beta-blockade, titrating to systolic BP 100-120 mmHg 1
- Critical pitfall: Never use vasodilators before beta-blockade, as this can cause reflex tachycardia and increased aortic shear stress
Diagnostic Imaging Orders
- 12-lead ECG immediately to document baseline rhythm and assess for ischemia or infarction 1
- Bedside transthoracic echocardiography (TTE) to evaluate aortic valve function, detect pericardial effusion, and visualize the proximal aorta 1
- CT angiography (CTA) of chest, abdomen, and pelvis with IV contrast as the primary diagnostic modality for definitive anatomic assessment 1
- This is the gold standard for characterizing aneurysm size, location, and extent
- Cardiovascular MRI (CMR) only if CTA is contraindicated (severe contrast allergy or renal failure) 1
Surgical Consultation
- Immediate cardiothoracic surgery consultation for all acute aortic syndromes and symptomatic aneurysms regardless of size 1
- Vascular surgery consultation for descending thoracic or abdominal aortic aneurysms 1
- Both services should be notified simultaneously upon admission to expedite decision-making
Additional Management Considerations
- Keep patient NPO (nothing by mouth) in anticipation of potential emergent surgical intervention
- Avoid anticoagulation unless specifically indicated, as this increases rupture risk
- Maintain adequate IV access and prepare for rapid transfusion if rupture occurs
- Pain control with IV opioids (morphine or fentanyl) while avoiding agents that cause tachycardia or hypertension
The cornerstone of initial management is aggressive blood pressure and heart rate control to reduce aortic wall stress while simultaneously obtaining definitive imaging and surgical consultation. 1 The 2025 guidelines emphasize that delays in ICU admission, invasive monitoring, or surgical consultation are associated with worse outcomes in acute presentations. 1