Don't get sued for missing an abdominal aneurysm
A young mother presented to an ED with abdominal pain, tachycardia, and hypotension, but after 45 minutes, she still had not been seen.
"Her mother went to the triage desk and asked when she would be evaluated, as she was in excruciating pain. The nurse visualized the patient and said she didn't know, as they were very busy," says Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant. "Witnesses in the waiting area confirmed that the patient was complaining of a lot of pain."
Another 45 minutes or so went by, and the patient still was not seen. A second set of vitals was not taken, and no further information was provided. "The patient at some point had considered leaving the emergency department because of the wait and had inquired about another facility," says Ridgely. "Although there was no indication that the patient actually left this particular emergency department, another three hours went by before she was called to be seen."
By that point, the patient's pain had subsided and she had left just prior to being called. "While en route, she became unresponsive and was taken to another facility by her mother. Upon arrival, she coded. This was approximately four hours after the initial presentation to the first emergency room. She did not survive, and the cause of death was determined to be an abdominal aneurysm."
The ED nurses at the first facility were named in a subsequent lawsuit, and the case is pending.
Abdominal aortic aneurysm (AAA) is a painless dilation of the aorta secondary to weakening of all layers of the aortic wall, says Melissa Gaines, RN, education clinical coordinator for emergency services at Sts. Mary & Elizabeth Hospital in Louisville, KY. "Once leaking or dissection starts to occur, the intense abdominal pain can be confused with pain of a renal stone during the triage assessment," Gaines says.
Christopher Cope, RN, associate nurse manager of the ED at Jewish Hospital Medical Center South in Hillview, KY, says, "Warning signs of AAA are sudden severe abdominal pain radiating to the back. Some patients may be in shock when they arrive with hypotension, tachycardia, cyanotic, and altered mental status."
The classic description of AAA is usually "tearing" or "ripping" pain that radiates to the back, leg, or kidney, notes Gaines. "However, nonclassic symptoms could indicate a AAA if a patient is age 60 or older; complains of low back pain; has a history of hypertension, smoking, diabetes, or elevated cholesterol; and a fall or trauma has been ruled out. The back pain will not relieve with position changes."
Gaines recommends monitoring your patient's blood pressure and "carefully administering narcotic pain medication, to avoid manifesting hypotension especially in a leaking rupture."
Subtle signs might result in mistriage, misdiagnosis, and poor outcomes, warns Cope. "Patients can complain of lower back pain, flank pain, abdominal pain, and have stable vital signs that would lead you to think kidney stone or something much less serious," he says. "The patient may end up in the waiting room and could potentially die if treatment was delayed."
Suspect AAA for these two pain complaints "Though prompt recognition of AAA [abdominal aortic aneurysm] rupture by its cardinal signs and symptoms is commendable, it may be too late for the patient," says James Cortez, RN, BSN, CEN, an ED charge nurse at Wake Forest University Baptist Medical Center in Winston-Salem, NC. Identifying the patient who presents with subtle signs and symptoms of an imminent AAA rupture or dissection "is where ED nurses can make a big difference," he says. "A complaint of lower back pain and/or flank pain, with no history of injury or kidney stones, should not be ignored, especially when the patient is a male over the age of 60 and when the patient's pain relief is not easily attained." |
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