if a hematoma is beginning to form in the groin after a cath.....

[raindrop]

I'm not a Cardiac nurse, but I am thinking of becoming one once I educate myself more on cardiac anatomy and cardiac procedures. So here come my first cardiac question of 2013:

where should the pressure be applied after a hematoma is forming post cath: On the hematoma? Above the insertion site?

I think the pressure should be just above the insertion site, to help prevent more blood loss.

Other nurses are saying it should be directly on the hematoma, but they can't tell me "why." Is it to prevent compartment syndrome? What happens to the blood that formed the hematoma after pressure is applied? Does it drain out of the body via insertion site? Or spread out and eventually dissolve?

[Rose_Queen, BSN, MSN, RN]

When we put pressure on a groin in the OR, it's directly on the insertion site. Once a hematoma forms, there are two ways for it to go away: surgical intervention, where it is evacuated and sometimes a drain is placed; or the body will dissolve it on its own. I believe size and continued bleeding are the determining factors whether to use a surgical approach.

[ccweisbard]

I've been told that it is proper to apply pressure 1" above the puncture site. The artery is just above where the incision is and you need to be applying pressure to where the hole in the artery is not where the puncture you can see is. We also "mash" the hematoma to make it softer, although beware that this is VERY painful to the patient....

[nursej22, MSN, RN]

Generally, you apply pressure above and medial to the puncture site. You should be able to palpate the pulse to be sure you are compressing the artery. It is helpful to have another person palpate pedal pulses for you to ascertain you are occluding the artery, or putting a pulse ox on the patient's great toe.

However, different docs enter the artery at different angles so the artery puncture may not always be just above the skin puncture. I had to pull bilateral sheaths placed by a radiologist. He warned me that the arteriotomy was up by the abdominal fold, nearly 4 inches above the skin puncture site.

[heartlover]

The most important factor is knowing how the artery was accessed as in which direction (retrograde vs antegrade)! That will depend how and where you hold pressure. If the artery was accessed retrograde (against blood flow) then I was taught to put the ring finger of my right hand over the puncture site seen on the skin and my index and middle fingers approx. 1" above the puncture site because that is where the actual puncture site of the artery is. Then place the left hand over the right hand to help steady your hands and apply further pressure. Hold pressure for at least 10 minutes for a freshly pulled catheter with or without forming hematoma or until hematoma begins to decrease in size.

It is the reverse if the artery was accessed antegrade (with blood flow). Place the index finger over the skin puncture site and the middle and ring fingers approx. 1" below the skin puncture.

I agree with other posters as well, palpate the artery by feeling it pulsate so you know you are compressing the correct spot and also adjust compression based on information from doctor.

[coco317]

At my hospital we hold manual pressure in the groin for 25-30 minutes or longer until hemostasis has occurred. We always have a second RN in the room (or occasional our PCA) to document q5 vs and check the pedal pulse and groin. If a hematoma is forming while holding pressure a second RN applies manual pressure to the hematoma. We have had as many as three nurses holding pressure on one patient. Definitely not fun! To answer the "why" it has always been my understanding that it helps to diffuse the hematoma.

[turnforthenurse, MSN, NP]

I have been taught (and it is also our policy) that we apply pressure 1" above the insertion site, forming your hand into a "C" so that your four fingers are on top holding pressure with your thumb underneath then your other hand on top. Pressure needs to be held for at least 20 minutes or until hemostasis has been achieved. There should always be two RNs certified to pull a sheath in the room. Patient should be hooked up to telemetry and the BP should cycle at minimum every 5 minutes. We place a pulse ox on the foot of the same side where the sheath was to make sure we aren't holding too much pressure that we are occluding blood flow. Make sure to have the extra RN check the pedal pulse and around the groin site, too. If a patient develops a hematoma, continue holding pressure and "mash" it out. The patient needs to be back on bed rest with the leg straightened and the cardiologist needs to be notified. As for the period of bed rest, that is the cardiologist's preference.

[MomRN0913]

2 finger breadths above the insertion site