A Patient with Splenic Artery Aneurysm Rupture and the Importance of Rapid Sonography in the ED

We report a case of a splenic artery aneurysm rupture presenting with shock which required timely embolization therapy. This case demonstrates how the rapid use of bedside ultrasound by emergency department (ED) physicians can help identify the cause of shock and, therefore, initiate appropriate treatment quickly even if the cause is rare, as in this case. 1. Introduction Emergency physicians often care for patients who are clinically in shock and it can be difficult to determine the cause of the symptoms. In some cases, bedside ultrasound performed by the physician can provide clues that will quickly lead to a definitive diagnosis and appropriate management which can save a life. 2. Case Report A 76-year-old Asian male was brought to the emergency department (ED) from a nearby hospital clinic. The man had had an episode of syncope and was found kneeling in a hallway near the hospital clinic where he had a follow-up appointment for a thyroid mass. Nurses and a doctor from the clinic responded to the scene, and they said the man reported left flank pain, dizziness, and one episode of vomiting just after falling. His vital signs measured by nurses at the scene included BP 80/40, PR 40, and SpO2 92% (on room air). They reported that his physical examination at that time showed anemic conjunctivae in both eyes but equal and reactive pupils, his chest was clear to auscultation bilaterally, and that heart sounds were unremarkable. Otherwise his physical exam was considered noncontributory. They gave him oxygen by nasal cannula (3？L/min) and 750？mL of normal saline intravenously (IV), but his hypotension did not improve. Consequently, the man was sent emergently to the ED about 30 minutes after the incident. His vital signs on arrival to the ED were BP 82/not palpable, PR 40, RR 18, T 36.3, and SpO2 84% (oxygen 10？L/min). His past medical history was not significant except for hypertension and a left thyroid mass. His past surgical history included left inguinal hernia repair. He took two antihypertensive medications, doxazosin 1mg QD and nifedipin 40？mg QD. He denied allergies to medications or foods. Significant laboratory studies included hemoglobin 11.9？gm/dL, hematocrit 37.4%, WBC 5,700/ L, and platelets 115,000/ L. Electrolytes, liver and renal function tests, and cardiac enzymes were all normal. Arterial blood gas (ABG) results were PaO2 157.1？mm Hg, PaCO2 42.6？mm Hg, and HCO3 25.3？mEq/L under oxygen 3？L/min. His CXR was within normal limits while his EKG showed sinus bradycardia without signs of cardiac ischemia. On physical exam, mild tenderness in