Rectus Sheath Hematoma Treatment & Management
- Author: Wan-Tsu Wendy Chang, MD; Chief Editor: Steven C Dronen, MD, FAAEM more...
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.
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.
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. 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. 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.
In 1980, Levy first described the transcatheter Gelfoam embolization technique in the treatment of rectus sheath hematoma. 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.
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.
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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