Head injury secondary to ruptured abdominal aortic aneurysm: an unusual presentation

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A 65-year-old male was admitted to the Accident and Emergency department following a road traffic accident in which his car hit a telegraph pole. It would appear that he collapsed at the whee1 just before the impact. He was wearing a seat belt. On arrival he was agitated and non-responsive with a BP of 100/50mmHg and a pulse rate of 104 beats/min. There was a large frontal laceration with an underlying haematoma. A rapid primary survey did not appear to reveal any other major injuries. A diagnosis of head injury was made. X-rays of the skull, cervical spine, chest, lumbar spine and pelvis were unhelpful. While the patient was still in the accident department he went into asystole. He was successfully resuscitated and at that point was noticed to have a large pulsating peri-umbilical mass. A diagnosis of ruptured abdominal aortic aneurysm was made. He was transferred immediately to the operating theatre. At laparotomy the presence of a large retroperitoneal haematoma associated with a ruptured infrarenal aortic aneurysm was noted. There was no free blood in the peritoneal cavity and no evidence of other intra-abdominal injuries. The aneurysm was repaired in standard fashion by a knitted Dacron tube graft and a total of 16 units of blood was transfused. After operation he was still ventilated and transferred to the X-ray department for a CT scan of the head which revealed no intra-cranial collection. He was returned to the intensive care unit and was ventilated for 3 days. His post-operative course was stormy, being complicated by a chest infection and jaundice, but he subsequently went on to make a good recovery and was discharged 24 days after operation. On review in the out-patient department 12 months later, he remains well.