massaging a hematoma post sheath removal

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    I work in a cardiac unit, a step down from ICU. We use telemetries and cardiac monitors on our patients. Our policy is to always have someone with u when a sheath is pulled. It was common practice to massage the hematoma if one formed within minutes of pulling out the sheath, but were recently notified that the Doctor got extremely mad when he found out about this stating that the hematoma will disperse itself. My coworkers and I have discussed this and wonder what happens if the hematoma gets hard as they can... how is this handled at your place of work??

    thanks

    michelle
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  3. 8 Comments so far...

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    I would be applying firm pressure for at least 5 minutes post sheath pull. Some facilities use what is called a Fem-stop to mechanically apply pressure for you. I would not be massaging a fresh hematoma, since you are trying to get that hole in the artery to clot over in a high pressure environment.

    Not good practice in my book.
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    If a hematoma forms, we apply firm manual pressure for 5-10 minutes and keep the patient down for another hour. The hematoma will soften and disperse once the bleeding is stopped. Before letting the patient up again, I will poke around at the site, because if the clot dislodges from a little poking, it's going to dislodge when the patient walks around. Better to poke around a bit and know you've got a good clot than to be too gentle and have a rebleed.
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    Apply pressure, no massaging. We can use a femstop when pulling a sheath but hardly ever do. I believe manual pressure is still the Gold standard.
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    We use a clamp for sheath pulls. I recall reading a research article for NS that basically concluded that using clamps did not increase the incidence of complications over using manual pressure. But for a hematoma, it's just manual pressure, since it's only a short duration. Another concern with using manual pressure is developing carpal tunnel syndrome in the personnel who hold pressure. Also, by using a clamp, I can keep pressure on the site while having hands free to write down frequent vitals, administer meds, etc. My understanding is that with certain meds, like Angiomax, the hold time really needs to be thirty minutes. Thirty minutes is a long time to hold manual.
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    Quote from Virgo_RN
    We use a clamp for sheath pulls. I recall reading a research article for NS that basically concluded that using clamps did not increase the incidence of complications over using manual pressure. But for a hematoma, it's just manual pressure, since it's only a short duration. Another concern with using manual pressure is developing carpal tunnel syndrome in the personnel who hold pressure. Also, by using a clamp, I can keep pressure on the site while having hands free to write down frequent vitals, administer meds, etc. My understanding is that with certain meds, like Angiomax, the hold time really needs to be thirty minutes. Thirty minutes is a long time to hold manual.
    :yeahthat:

    We too use clamps and Fem-Stops, mostly for the above mentioned reason. And we also use manual pressure for hematomas, unless it is a rapidly expanding one.

    my $0.02

    Tom
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    Agree- we use manual pressure, femstops, and/or sandbags... no massage
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    I have witnessed many a CCL tech and a cardiologist or two massage a forming hematoma at the same time they were holding manual pressure. The cardiologist was essentially "milking" the hematoma from the cath puncture. Although I sort of see what they are trying to do, I'd never attempt that myself. I'd reevaluate my positioning and intensity of the pressure to prevent the hematoma from enlarging. Depending on the size and location of the hematoma, sometimes they need to be surgically removed.
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    "Mash out" the hematoma. If the pt developes a hematoma... hopefully someone is holding manual pressure at the same time of mashing it out. A hematoma itself is not enough pressure to stop an active bleed. The standard hold time is 5min for every French size used. For example: 6fr sheath= 30min; 8fr Sheath= 40min. Only 10-15min of this time will be total occlusive pressure. A mere 5min of holding will not stop an active arterial bleed. The rebound alone will cause another.


    CathLab RN


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