Sweep through large AAA from Sinai EM Ultrasound on Vimeo.

Abdominal aortic aneurysm (AAA) affects 5-10% of males age 65-79, and among males over 55 years of age represents the 14th leading cause of death. Ruptured aortic aneurysm is associated with a very high mortality rate. Up to 80% of patients die by the time they reach the hospital, and half die during emergent operative repair.

Evaluation of the abdominal aorta by emergency physicians using point-of-care sonography has been a core indication since ACEP’s first ultrasound guidelines were published in 2001. Several studies have demonstrated sensitivity and specificity for aneurysm which approach those of Radiology Department performed ultrasounds, and even CT scans.

While many providers have adopted a point-of-care assessment strategy in patients where AAA is suspected, it is debatable whether emergency physicians should engage in screening asymptomatic patients for AAA. Several ED-based studies have found aneurysms in 5-7% of asymptomatic male patients over the age of 65. Screening has been shown to reduce mortality from AAA, and is recommended by the U.S. Preventive Services Task Force. A single screening examination for asymptomatic males over age 65 is covered by many insurers in the United States including Medicare (Medicare requires that you have smoked over 100 cigarettes or have a family history of AAA to qualify for coverage).

So there is evidence that emergency physicians are capable of screening for aneurysm, and there is evidence to support that someone should be screening selected elder patients. Whether emergency physicians should engage in screening will depend on ED resources available. Many departments across the country have screening programs for HIV, abuse, and other pathology. There is a balance between using limited resources to diagnose and treat acute illness and deploying resources to impact the long-term health of a population which might otherwise be lost to follow up.

So you decide!

Further reading:

  • Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med 2003 (PMID: 12896888)
  • Costantino TG, Bruno EC, Handly N, Dean AJ. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. J Emerg Med 2005 (PMID: 16243207)
  • Knaut AL, Kendall JL, Patten R, Ray C. Ultrasonographic measurement of aortic diameter by emergency physicians approximates results obtained by computed tomography. J Emerg Med 2005 (PMID: 15707804)
  • Salen P, Melanson S, Buro D. ED screening to identify abdominal aortic aneurysms in asymptomatic geriatric patients. Am J Emerg Med 2003 (PMID: 12671815)
  • Moore CL, Holiday RS, Hwang JQ, Osborne MR. Screening for abdominal aortic aneurysm in asymptomatic at-risk patients using emergency ultrasound. Am J Emerg Med 2008 (PMID: 18926345)
  • Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev. 2007 (PMID: 17443519)
  • Hoffmann B, Um P, Bessman ES, Ding R, Kelen GD, McCarthy ML. Routine screening for asymptomatic abdominal aortic aneurysm in high-risk patients is not recommended in emergency departments that are frequently crowded. Acad Emerg Med. 2009 (PMID: 20053243)