• David Metcalfe, Kapil Sugand, Sri G Thrumurthy, Matthew M Thompson, Peter J Holt, and Alan Prasanna Karthikesalingam.
• St George's Vascular Institute, 4th Floor St James' Wing, St George's Hospital, London, UK.
• Eur J Emerg Med. 2016 Oct 1; 23 (5): 386-90.

ObjectiveThe aim of this study was to describe the presentation of patients with ruptured abdominal aortic aneurysm (rAAA) and identify factors contributing toward misdiagnosis.MethodsThis was an observational study of cases with a final diagnosis of rAAA assessed at nine Emergency Departments and managed at one of two regional vascular centres in the UK.ResultsEighty-five consecutive cases were included. Seventeen [20.0%, 95% confidence interval (CI) 11.5-28.5%] patients reported important symptoms up to 3 weeks before index presentation. In the Emergency Department, most patients complained of abdominal and/or back pain, seven (8.2%, 95% CI 2.4-14.0%) additionally reported atypical pain and ten (11.8%, 95% CI 4.9-18.7%) denied pain altogether. Hypotension (36.5%, 95% CI 26.3-46.7%), tachycardia (18.8%, 95% CI 10.5-27.1%) and syncope (36.5%, 95% CI 26.3-46.7%) were documented in a minority of cases. Distracting symptoms were present in 33 (38.8%, 95% CI 28.4-49.2%) patients. The median time to diagnosis was 17.5 min (range immediate-12 days), and 21 (25.6%, 95% CI 16.3-34.9%) patients were misdiagnosed during clinical assessment.ConclusionThe classical signs and symptoms or rAAA are not always present and patients frequently show additional features that may confound the diagnosis. A high level of suspicion should be adopted for rAAA alongside a low threshold for immediate computed tomography. Further research is required to develop an objective clinical risk score or predictive tool for characterizing patients at risk.

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