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  1. 1. The Coronal image demonstrates a large infra renal dilated and elongated AAA with luminal contrast and mural thrombus. There appears to be extravasation of contrast into the retroperitoneum with associated haematoma. Difficult to tell from the images but there is likely extension into one or more of the common Iliac arteries. There is also extensive calcification of the abdominal aorta. There is also note of previous internal fixation of the lumbar spine apparent on the sagittal image. The presumably ruptured AAA is the likely cause of the patient’s abdominal pain.

    2. Management: ABCs as a first step. IV access (2x large bore cannulas or IO if required). Blood pressure control, aiming for a systolic pressure of 50-100 (permissive hypotension, avoiding large volumes of crystalloid and using vasopressors if required). Bloods including Cross match, VBG, FBE, EUC, CMP, Coags. Contact blood bank for consideration of massive transfusion protocol. Analgesia (IV/IO). Discuss with Surgical team (Vascular/General plus Anaesthetics + ICU) for consideration of immediate transfer for OT for definitive management (Endovascular or open) or Transfer to major centre if not available onsite and Pt stable enough. Above referral made giving consideration to Patient/Family regarding wishes (Advanced care directive etc).

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