Abdominal hematoma post angiogram

[redandblue]

Hi all nurses,

I have a question regarding a abdominal hematoma post angiogram. I had a patient who had angiogram 4 days ago. She had a huge hematoma on the Left femoral site. Yesterday, she was complaining a new pain at the left lower abdominal site where there was hematoma plus a "lump". She said the abdominal hematoma was there at the same time as her femoral hematoma post angiogram but she only started to have pain yesterday. Her vital signs was good (BP:108/60, HR:80-90s, spO: 96% on R/A). She was on heparin drip at 7cc/h for A.fib. No abdominal distention. I even asked the nurse in charge to come and check and she said it could be normal post angiogram

Since it's the first day I had her, I don't know how long the "lump" and the abdominal hematoma has been there. There is no documentation about the abdo hematoma as no one was checking her abdomen I circled the hematoma and told the patient if she saw expansion of the hematoma she need to tell the nurse.

When I got home, I was puzzled by the hematoma. I did further research online and it turns out it could be a retroperitoneal hematoma, which is dangerous!!!!! Now I'm scared the patient may be in danger because I told the doctor it was a hematoma so she didn't check it herself, plus the nurse in charge said it could happen post angio and it's normal

Please guys, I need your input on this. Thank you very much !!!!

[KatieMI, BSN, MSN, RN]

Retroperitoneals are pretty common, especially with modern insane passion to anticoagulate every thing that still breathes. The aorta and its bifurcation lies behind the posterior peritoneum, together with kidneys and adrenals; the femoral arteries (and veins) run out from retroperitoneal space and blood from femoral artery can thus enter back into it. This POTENTIAL space (as in norm it does not exist) can contain 2000 cc of blood and more.

https://en.m.wikipedia.org/wiki/Retroperitoneal_space to start from.

Now, these bleedings are bad because there is very few ways one can access the space without cutting or imaging. One thing characteristic is new pain on the one side of the abdomen, side AND back, all together. It may look like back pain, but repositioning does not help. Abdomen remains benign and soft, with no guarding and such. New hematoma may be present or absent, old one may increase or remain stable. If patient receives opioids early in the process, the BP/HR reaction is often exaggerated (you expect BP to drop, but not that much). Sometimes, but not often, patients can start have "bruises" over flank(s) and mid-upper back, like ones seen in acute pancreatitis. Later, the patient shows symptoms of classic hemorragic shock. There is usually no early urinary symptoms as the process us mostly unilateral, but drop in output may happen as result of shock.

If I get just such patient, I would access VSs q1-2 hours and ask especially about back pain, as it is early and commonly seen symptom. If it happens, I would not leave attending alone till I get orders either for H&H q4-6, MRI or both and for the God's sake to stop anticoags. Marking of hematoma goes without words but in reality it is kinda useless, as the main blood collection is where it cannot be seen. I would also throw in Foley, check IV access, hold all lowering BP meds and everything which can affect coags like Motrin. The treatment usually is one of shock (blood, fluid resustitation, pressors as needed) and something like Femstop for the next 24 hours or so. And holding that d*** anticoagulation!

[redandblue]

Hi KatieMI! Thank you for the reply. What is the timeline from patient had angio to going to a hemorragic shock? The patient was angio post-op day 4 or 5

[redandblue]

The patient's BP was 108/60 (her baseline had been around 100 systolic) and HR was 80s-90s. She didn't complain of dizziness, nausea, headache, feeling weak etc through out the day and she was walking around using the walker. That's why I wasn't too worried till now I did more research on retroperitoneal hematoma!!!

[KatieMI, BSN, MSN, RN]

There is no clear timeline. Retroperitoneals are classicaly described as late complication just because it takes time for enough blood to seep there. 4 to 5 days is kinda late, but if the patient was anticoagulated, timelines won't work anymore.

Looks like this time the bad thing did not happen, but next one you'll know what to look for:up: