title: [A man in his fifties with syncope and hypotension].
abstract: A man in his fifties was admitted to our hospital because of  syncope and hypotension. In the emergency room he reported abdominal pain,  but focused assessment with sonography for trauma (FAST) was negative.  His systolic blood pressure varied between 60 and 90 mmHg and an  arterial blood gas revealed lactic acidosis with normal haemoglobin, which  still might indicate acute bleeding. An ECG did not indicate myocardial  infarction. In the absence of an obvious bleeding focus, the patient  was urgently transported to a CT lab nearby, to identify possible  bleeding and rule out other causes of circulatory shock, such as  cardiac tamponade. Before radiologic scanning was initiated, the  patient lost consciousness and displayed pulseless electrical activity.  Resuscitation was initiated and pericardiocentesis was resultless.  On vital indication and clinical suspicion of cardiac tamponade,  an emergency median sternotomy was performed and a haematoma was evacuated  from the pericardial space. The patient was stabilised and immediately  taken to the operation theatre where a ruptured ascending aortic  aneurysm was identified. The operation was successful, but following serious hypoperfusion,  the patient suffered acute kidney failure requiring dialysis for several  months, gram-negative septicaemia caused by a central venous catheter,  cerebral infarction leading to hemiparesis and impaired vision,  ventilator-associated pneumonia/acute lung injury and acalculous  cholecystitis. This case report describes the findings on admission,  the diagnostic process including surgical resuscitation and a complicated  course of multi-organ failure. After almost 5 months, the patient  was discharged from our hospital to another institution for further  rehabilitation. He now has minimal sequelae and lives at home. Our take-home  message is that seriously ill patients require fast, resolute and  broad examination; they may need immediate surgical treatment including  emergency intervention; and a good clinical outcome may be achieved in  spite of serious complications.
authors.affiliation: Nyremedisinsk avdeling, Oslo universitetssykehus, Ullevål, Norway. geir.christian.e.mordal@ahus.no
authors.forename: Geir Christian Enli
authors.initials: GC
authors.lastname: Mordal
authors.forename: Karen Roksund
authors.initials: KR
authors.lastname: Hov
authors.forename: Johannes Lagethon
authors.initials: JL
authors.lastname: Bjørnstad
authors.forename: Nina Knutrud
authors.initials: NK
authors.lastname: Meidell
mesh_terms: D001019:Aortic Rupture / Q000150:complications / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000601:surgery; D003937:Diagnosis, Differential; D006801:Humans; D007022:Hypotension / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000628:therapy; D011183:Postoperative Complications / Q000628:therapy; D011859:Radiography; D013575:Syncope / Q000175:diagnosis*