helpful in the majority of other causes of pain and can decrease the rate of a negative laparotomy. Obvious symptoms and signs of a surgical abdomen, however, are best evaluated with a laparotomy. Pain can be treated, particularly after the examination. Consider morphine or fentanyl intravenously as these will decrease the patient’s anxiety and will not mask the evidence of peritonitis. There is no evidence that treating the pain has an adverse effect on the patient’s outcome and will keep the patient more comfortable during the workup of the pain.
AORTIC ANEURYSM In the emergency room, managing an aortic aneurysm usually means managing an aortic dissection. With an aortic dissection, there is a tear in the intimal layer of the artery with blood surging through the tear, leading to a false passage and secondary hemorrhage. Any part of the aorta may be affected with a dissection. The major predisposing factor for this is hypertension. Patients with an aortic dissection can have the sudden onset of chest or back pain that can be severe. About 20 percent of patients die before they are seen in the ED, while an additional third will die in surgery or from postoperative complications. It is particularly common in African-Americans, the elderly, and those with underlying hypertension. The peak ages are between 50 and 65 years of age. Patients who have Ehlers-Danlos syndrome or Marfan syndrome have an increased risk of dissection at a younger age. Figure 1 shows what a dissecting aortic aneurysm looks like:
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