SUMMARYThis case describes the unexpected survival of an adult man who presented to the emergency department with hypovolaemic shock secondary to a splenic haemorrhage. Before surgery he had a pH 6.527, base excess (BE) −34.2 mmol/l and lactate 15.6 mmol/l. He underwent a splenectomy after which his condition stabilised. He was managed in the intensive care unit postoperatively where he required organ support including renal replacement therapy but was subsequently discharged home with no neurological or renal deficit. Although there are case reports of patients surviving such profound metabolic acidosis these have mainly been cases of near drowning or toxic alcohol ingestion. To the best of our knowledge this is the first reported case of survival after a pH of 6.5 secondary to hypovolaemic shock.
CASE PRESENTATIONA 65 year old man presented to the emergency department after a collapse at home. There had been no preceding symptoms or illness. He had a past medical history of atrial fibrillation, gout and acne rosacea and his drugs comprised digoxin, aspirin, omeprazole and oxytetracycline. He did not receive warfarin.On initial assessment he was shocked with cool peripheries and hypotension, in atrial fibrillation with a heart rate of 90 and a blood pressure of 80/40 mm Hg. He was apyrexial with no evidence of cardiac failure and no complaints of chest pain. He had mild, diffuse tenderness at his epigastrium but no peritonism. There was no evidence of gastrointestinal blood loss.Routine blood investigations showed a raised white cell count at 16.0×10 9 /l and normal haemoglobin of 12.6 g/dl. Venous blood gas analysis showed a lactate level of 5.4 mmol/l but was otherwise unremarkable.He received 3 litres of 0.9% NaCl over the next 2 h with no improvement in his haemodynamic profile. He then rapidly deteriorated with severe abdominal pain and increasing agitation. A plan to obtain an abdominal CT scan was abandoned owing to haemodynamic instability and agitation. An abdominal ultrasound scan in the resuscitation room showed minimal free fluid and no evidence of an abdominal aortic aneurysm or solid organ abnormality. Treatment was started with an adrenaline infusion and he underwent rapid sequence induction and intubation in the emergency department. After resuscitation from a brief pulseless electrical activity (PEA) cardiac arrest he was transferred to theatre for an emergency laparotomy. On arrival in theatre he had a profound metabolic acidosis with a pH of 6.527 (hydrogen ion 313 nmol/l), base excess (BE) −34.2 mmol/l and lactate 15.6 mmol/l, see figure 1. At this point he had a blood pressure of 58/32 mm Hg, heart rate 150 bpm, arterial oxygen saturation (SaO 2 ) 90% on fractional inspired oxygen (FiO 2 ) 0.98 and core temperature of 34°C. He continued with an adrenaline infusion.Laparotomy showed marked bleeding from the distal splenic artery. This was ligated and a splenectomy was performed, although the spleen itself appeared to be intact. After this the brisk bleeding settled and the abdomen was closed...
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