10 November 2007

The Sh*t hits the fan

I posted the other day about a satisfying evening in which I was fortunate enough to see a number of acute cases in a row. Frankly, none of them took a ton of diagnostic acumen -- bread and butter stuff for emergency medicine, really. It was, though, a nice day.

One thing that struck me about a particular case was how quickly it went bad -- very very bad.

It was a woman in her child-bearing years who suddenly collapsed (i.e. syncope) while watching a football game. She came in looking ill but with stable vital signs, complaining of severe abdominal pain which had come on at the moment she fainted. Her hematocrit on arrival was 27 -- indicating either chronic anemia or acute blood loss.

So I'm no dummy -- the first thing I thought of was a ruptured ectopic pregnancy. But her pregnancy test came back negative. I am an experienced ultrasonographer -- don't ask me to find the common bile duct, but I can see blood very reliably if it is there. So I dropped the ultrasound probe on her abdomen, and the results were perplexing. There was definitively no blood in Morrison's pouch, or in the spleno-renal recess, or in the pelvis. There was an odd hypoechoic stripe across the body of the liver. It looked like a blood vessel, but was too linear. In retrospect it was probably blood in the falciform fissure, or some anomalous similar structure. But again, there was clearly no free blood in the peritoneum at that time. But based on that odd finding, I called in the ultrasound tech for a formal study.

A very short time later (it was chaotic -- fifteen minutes?), she crashed. She became unresponsive and profoundly hypotensive, with a heart rate around 150 (from the 80's). Annoyingly, in her throes as she passed out, she managed to pull out both her IVs. A repeat hematocrit came back at 21 -- she was clearly losing blood rapidly; the ultrasound tech arrived while we were re-establishing IV access and beginning aggressive volume and blood resuscitation. He dropped the probe on the abdomen and I uttered a four-letter word, because the DRY abdomen I had seen shortly before was now FULL of fluid.

Fortunately, it was not difficult to persuade the on-call surgeon to come in and take this young lady directly to the operating room. The surgeon did a superb job to stanch the bleeding (from her ruptured Splenic Artery Aneurysm) and perform an emergency splenectomy. The patient survived (thanks in no small part to the Cell Saver) and did very well.

What was striking was how very quickly she went from "ill-but-stable" with an empty belly to "moribund-with-belly-full-of-blood." Amazing.

5 comments:

Graham said...

How'd she rupture her spleen?

shadowfax said...

Ah, my bad. This was the Splenic Artery Aneurysm case I referred to before. I've updated to clarify.

Anyway, I gather that a splenectomy is more or less obligatory with this sort of thing. Usually the anatomy is distorted and the artery is not easily repairable, so out it comes!

House Whisperer said...

Splenic artery aneurysm doesn't sound so bread and butter to me. Can't say I've ever seen that. Good case.

Aggie Sarah said...

I'm glad she's ok. I'm also excited about it because I've just learned where exactly the splenic artery is! Thanks for sharing what's going on in your medical life.

shadowfax said...

House --

Splenic artery aneurysm isn't bread & butter for a surgeon -- it's a crazy zebra. Hemoperitoneum and hemorrhagic shock are, however, bread & butter for an ER doc.

Beyond general curiosity, what they find in the belly once they get upstairs doesn't much matter to me, so long as I get them there.