[zacarias]

Hey all,

I work on a tele/med/surg floor that is RARELY takes care of post-groins as that is done on another tele floor/interventional unit.
I take care of R/O MIs, post-CABGs, afibers, chfers etc... My question is r/t to one s/p CABG recently. On the leg where they took a couple veins, he had MAJOR bruising and it was definitely pitting. It seemed hard in a few places like a hematoma. The surgeon noted ecchymosis on his progress notes but this was a couple days earlier. I marked it.
The next day I was looking at it and it seemed that the bruising has started in other places and that his knee was possibly bigger. I marked it, and showed my charge nurse, and began taking serial circumferential measurements below and above the knee to see if it was getting bigger. His HCT was stable BUT his PLTs were 108, however they had been 83 the day before.
I left a note for the doc and gave a good report to the oncoming shift about this but I have a couple questions.
I always thought a hematoma was hard like a tennis ball. Can it sometimes be soft and pitting or would you just call that ecchymosis? Also, sorta unrelated, what's the point of expressing a hematoma post-sheath removal. Hematomas can hurt so bad that it would seem expressing would make hurt more only for putting pressure on the hematoma?
Thanks for any info!

Zman

[glea1022]

I'm a cath lab RN, and my opinion of expressing a groin hematoma is to relieve pressure on the nerve and vasculature in the groin so that you don't end up with lack of distal flow.

[Dinith88]

Originally Posted by zacarias

Hey all,

I work on a tele/med/surg floor that is RARELY takes care of post-groins as that is done on another tele floor/interventional unit.
I take care of R/O MIs, post-CABGs, afibers, chfers etc... My question is r/t to one s/p CABG recently. On the leg where they took a couple veins, he had MAJOR bruising and it was definitely pitting. It seemed hard in a few places like a hematoma. The surgeon noted ecchymosis on his progress notes but this was a couple days earlier. I marked it.
The next day I was looking at it and it seemed that the bruising has started in other places and that his knee was possibly bigger. I marked it, and showed my charge nurse, and began taking serial circumferential measurements below and above the knee to see if it was getting bigger. His HCT was stable BUT his PLTs were 108, however they had been 83 the day before.
I left a note for the doc and gave a good report to the oncoming shift about this but I have a couple questions.
I always thought a hematoma was hard like a tennis ball. Can it sometimes be soft and pitting or would you just call that ecchymosis? Also, sorta unrelated, what's the point of expressing a hematoma post-sheath removal. Hematomas can hurt so bad that it would seem expressing would make hurt more only for putting pressure on the hematoma?
Thanks for any info!

Zman

When you're talking ecchymosis(sp?) you mean bruise...hematoma is collection of blood that is 'pooling'...and causing (usually) a lump/bump/pocket. As far as sheath pulling is concerned, the bigger issue is a hematoma..because it indicates that hemostasis has not been acheived, etc. Brusing (ecchymosis) is no big deal because some blood will(usually) leak(sp?) into tissue even if sheath-hold was good.

NOw...the issue you're having is a day or two..(or few days)post-op and (probably) a few days post sheath-removal. The leg that has had the SVG harvest is now less able to move blood (venous blood) because the saphenous vein has been removed/resected. As a result, unilateraL edema is relatively common...but not because of hematoma. It's due to poor venous return on top of SVG harvest...etc. Swelling may indeed be occuring..(as you noted) but it's probably not a hematoma.and not needing reduced/expressed because the edema you're noting is 'edema' rather than hematoma...do you catch the drift?...

[Dinith88]

Originally Posted by Dinith88

When you're talking ecchymosis(sp?) you mean bruise...hematoma is collection of blood that is 'pooling'...and causing (usually) a lump/bump/pocket. As far as sheath pulling is concerned, the bigger issue is a hematoma..because it indicates that hemostasis has not been acheived, etc. Brusing (ecchymosis) is no big deal because some blood will(usually) leak(sp?) into tissue even if sheath*hold was good.

NOw...the issue you're having is a day or two..(or few days)post*op and (probably) a few days post sheath*removal. The leg that has had the SVG harvest is now less able to move blood (venous blood) because the saphenous vein has been removed/resected. As a result, unilateraL edema is relatively common...but not because of hematoma. It's due to poor venous return on top of SVG harvest...etc. Swelling may indeed be occuring..(as you noted) but it's probably not a hematoma.and not needing reduced/expressed because the edema you're noting is 'edema' rather than hematoma...do you catch the drift?...

woops...i think i kinda mis*understood the point of your question in my last response...
and i guess the point i was trying to make is that if the severely bruised area is pitting (like edema) on the leg w/the SVG harvest, it's probably just edema. If it were hematoma then yes...it'd be a 'hard' lump/mass (with easily defined borders) that in general does not pit. If you're concerned that the SVG harvest might be leaking you're correct in that it'd more likely present as hematoma. If the entire leg is swelling (and pitting) it's probably edema exacerbated by poor venous return post*harvest. If it's a few days post surgery, it's very unlikely to be a leaky SVG harvest.

[zacarias]

Thanks for your explanation. It turned out the doctor wasn't worried and the guy was d/ced later that way. Of course he was admitted again the next day!!! for something diff though...

[Marnaby]

Although it does hurt to put pressure on a groin hematoma it's also VERY necessary. Otherwise your patient will continue to bleed from the artery/vein that was punctured under the skin. Then you get into low Hcts and BPs and no one wants that