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Rectus Sheath Hematoma Treatment & Management

  • Author: Wan-Tsu Wendy Chang, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
 
Updated: Nov 02, 2014
 

Emergency Department Care

Once rectus sheath hematoma (RSH) is diagnosed, the patient's clinical condition determines appropriate treatment and disposition. Treatment may be either conservative or invasive.

Conservative treatment is appropriate for patients who are hemodynamically stable and have small nonexpanding hematomas in which symptoms are mild and the diagnosis is certain. Conservative treatment of rectus sheath hematoma includes rest; analgesics; hematoma compression; ice packs; treatment of predisposing conditions; and if necessary, more aggressive therapies of intravenous fluid resuscitation, reversal of anticoagulation, and transfusion. Care must be taken in applying a conservative approach because even a relatively small hematoma has been reported to cause hypotension and death in a patient who is debilitated. Conversely, in 2000, Berna et al's case series of 12 patients with rectus sheath hematoma who were all undergoing anticoagulant therapy and treated conservatively had no reported mortality even though 7 of the patients initially had hemodynamic instability and anemia. These patients demonstrated improvement in their general condition 3-5 days after diagnosis.[4]

Anticoagulation reversal

Patients who are undergoing invasive procedures and those with hemodynamic instability, expanding hematomas, or symptomatic anemia should be considered for anticoagulation reversal. For patients taking oral anticoagulation, reversal can be achieved with phytonadione plus fresh frozen plasma (FFP). The patient's clinical condition determines the aggressiveness of anticoagulation reversal.

Intravenous phytonadione can be administered at a dose of 1-10 mg. Intravenous phytonadione is associated with rare but well-documented cases of anaphylactoid reactions; thus, it must be administered with care at a rate no greater than 1 mg/min, with frequent (every 15 min, 30 min, and 1 h) vital sign measurements. A patient given a dose of 10 mg of intravenous phytonadione may be refractory to Coumadin for several weeks, making 2.5 mg or 5 mg a better dose in all but the most severe RSHs.

Subcutaneous phytonadione is associated with an unpredictable therapeutic response and is not recommended.

Oral phytonadione has a time to onset that is too slow for a patient who is actively bleeding.

FFP is administered in a volume of 15 mL/kg and provides coagulation factors for as long as 8 hours. FFP may have to be administered with diuretics if volume overload is a concern.

Patients on heparin can have coagulation reversed by protamine at a dose of 1 mg per 100 U of heparin. Heparin has a half-life of 60 minutes. A dose of protamine reverses all of the heparin administered in the past hour, one half of the heparin of the previous hour, and one fourth of the heparin given 2 hours previously, assuming that no recent bolus has been administered.

Patients on LMWHs can have their anticoagulation partially reversed by protamine, although refractory heparinoid fractions are present.

Transfusion

The decision to transfuse is made depending on the patient's need for fluid resuscitation; the presence of comorbid conditions, such as active coronary ischemia; the degree of anemia; and the need for an operative procedure for control of bleeding. In 1988, Zainea reported the transfusion of blood in 4 of 8 patients in a case series, although none of the patients were hemodynamically unstable.[10] In Berna's case series of 12 anticoagulated patients in 2000, all 5 patients with type III hematomas required transfusion and had alterations in hemodynamic variables.[4] Transfusion requirements are generally 2-6 U of packed red blood cells.

Two main modalities exist for invasive control of active bleeding in rectus sheath hematoma: (1) therapeutic angiography with embolization of the bleeding vessel and (2) operative therapy with clot evacuation, ligation of bleeding vessels, and closed-suction drainage. Invasive treatment should be considered in patients with enlarging hematomas, hemodynamic instability unresponsive to fluid resuscitation, peritoneal signs, pain not well controlled with analgesics, and persistent gastrointestinal or urinary symptoms. Patients with significant comorbidities may not be candidates for invasive therapy.

Arterial embolization

In 1980, Levy first described the transcatheter Gelfoam embolization technique in the treatment of rectus sheath hematoma.[16] This invasive therapy can produce hemostasis, reduce the size of the hematoma, decrease the need for blood product transfusion, and prevent rupture into the abdomen. Embolization with thrombin, Gelfoam, or coil is an alternative to surgery for conditions not responding to conservative management.

Operative exploration

Surgical treatment includes evacuation of the hematoma, ligation of bleeding vessels, repair of the rectus sheath, drainage (when indicated), and closure of the abdominal wall. Recurrences following surgical therapy have not been reported.

The decision to admit a patient with rectus sheath hematoma depends on the clinical data regarding hemodynamic status and comorbid conditions as well as the size of the hematoma. Patients on anticoagulation therapy should be admitted to ensure that the hematoma is not expanding and to plan restarting anticoagulation as appropriate. In general, patients with type I hematomas do not require hospitalization. Patients with type II and type III hematomas usually do require hospitalization. Patients with type II hematomas can be admitted to the floor during the first 24-48 hours to evaluate evolution of the hematoma. Patients with type III hematomas often present with hemodynamic instability requiring fluid resuscitation and blood transfusion that is best managed in the intensive care unit setting.

Postdischarge care includes rest, analgesics, hematoma compression, ice packs, and treatment of predisposing conditions. Type I hematomas resolve after approximately 1 month. Type II hematomas require 2-4 months, and type III hematomas require more than 3 months and as long as a year for complete resolution.

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Consultations

All patients who are admitted for rectus sheath hematoma (RSH) should have a surgical consultation, either general or vascular, depending on the institution. The diagnosing clinician should also consider surgical or primary care consultation for discharged patients and provide follow-up evaluation and long-term pain control.

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Contributor Information and Disclosures
Author

Wan-Tsu Wendy Chang, MD Fellow in Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine

Wan-Tsu Wendy Chang, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Neurocritical Care Society

Disclosure: Nothing to disclose.

Coauthor(s)

Andra L Blomkalns, MD Associate Professor, Vice Chair - Academic Affairs, Department of Emergency Medicine, University of Cincinnati School of Medicine

Andra L Blomkalns, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

William A Knight IV, MD Assistant Professor, Department of Emergency Medicine, Assistant Professor, Department of Neurosurgery, Division of Neurocritical Care, University of Cincinnati College of Medicine

William A Knight IV, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Emergency Medicine Residents' Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Genentech, Inc.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Attending Physician in Emergency Medicine, Excela Health System

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

Acknowledgements

Steven G Werdehoff, MD Consulting Staff, Department of Emergency Medicine, Huntsville Emergency Physicians Group

Steven G Werdehoff, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Teske JM. Hematoma of the rectus abdominis muscle: report of a case and analysis of 100 cases from the literature. Am J Surg. 1946. 71:689-95.

  2. Berna JD, Garcia-Medina V, Guirao J, Garcia-Medina J. Rectus sheath hematoma: diagnostic classification by CT. Abdom Imaging. 1996 Jan-Feb. 21(1):62-4. [Medline].

  3. Klingler PJ, Wetscher G, Glaser K, et al. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc. 1999 Nov. 13(11):1129-34. [Medline].

  4. Berna JD, Zuazu I, Madrigal M, et al. Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy. Abdom Imaging. 2000 May-Jun. 25(3):230-4. [Medline].

  5. Fothergill WE. Hematoma in the abdominal wall simulating pelvic new growth. Br Med J. 1926. 1:941-2.

  6. Sheth HS, Kumar R, DiNella J, Janov C, Kaldas H, Smith RE. Evaluation of Risk Factors for Rectus Sheath Hematoma. Clin Appl Thromb Hemost. 2014 Oct 7. [Medline].

  7. Ko SB, Choi HA, Malhotra R, Lee K. Giant rectus sheath hematoma after therapeutic paracentesis resulting in hemodynamic instability in the intensive care unit. Hosp Pract (Minneap). Jun 2010. 38(3):52-5. [Medline].

  8. Auten JD, Schofer JM, Banks SL, Rooney TB. Exercise-induced bilateral rectus sheath hematomas presenting as acute abdominal pain with scrotal swelling and pressure: case report and review. J Emerg Med. Apr 2010. 38(3):e9-12. [Medline].

  9. Kaftori JK, Rosenberger A, Pollack S, Fish JH. Rectus sheath hematoma: ultrasonographic diagnosis. AJR Am J Roentgenol. 1977 Feb. 128(2):283-5. [Medline].

  10. Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg. 1988 Oct. 54(10):630-3. [Medline].

  11. Fukuda T, Sakamoto I, Kohzaki S, et al. Spontaneous rectus sheath hematomas: clinical and radiological features. Abdom Imaging. 1996 Jan-Feb. 21(1):58-61. [Medline].

  12. Unger EC, Glazer HS, Lee JK, Ling D. MRI of extracranial hematomas: preliminary observations. AJR Am J Roentgenol. 1986 Feb. 146(2):403-7. [Medline].

  13. Herzan FA. Roentgenologic diagnosis of rectus sheath hematoma. Am J Roentgenol Radium Ther Nucl Med. 1967 Oct. 101(2):397-405. [Medline].

  14. Monsein LH, Davis M. Radionuclide imaging of a rectus sheath hematoma caused by insulin injections. Clin Nucl Med. 1990 Aug. 15(8):539-41. [Medline].

  15. Osinbowale O, Bartholomew JR. Rectus sheath hematoma. Vasc Med. 2008 Nov. 13(4):275-9. [Medline].

  16. Levy JM, Gordon HW, Pitha NR, Nykamp PW. Gelfoam embolization for control of bleeding from rectus sheath hematoma. AJR Am J Roentgenol. 1980 Dec. 135(6):1283-4. [Medline].

 
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Anatomy of the rectus sheath.
The Cullen sign, periumbilical ecchymosis, in a patient with a rectus sheath hematoma.
Rectus sheath hematoma of the right rectus muscle. Image courtesy of Dr David Gordon.
Note how the rectus sheath hematoma becomes bilobar as it dissects inferiorly (same patient as in the previous image). Image courtesy of Dr David Gordon.
Ultrasound image of a rectus sheath hematoma presenting as a tender, unilateral abdominal mass. D Maharaj, M Ramdass, S Teelucksingh, A Perry and V Naraynsingh; Rectus sheath haematoma: a new set of diagnostic features. Postgraduate Medical Journal 2002;78:755-756. Reproduced with permission from the BMJ Publishing Group.
 
 
 
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