Hematoma after heart cath

thewandereRN · Feb 26, 2015

In my experience, the actual sheath insertion is usually at an angle, so you'd want to hold pressure two fingers about the puncture site (where you would be checking pulses normally)so that you are able to completely compress that artery so the bleeding is stopped. Hydration is good, and you may want to obtain a CBC, to compare. monitor vitals. While one person holds pressure, someone else should be calling the doc stat, if visible or palpable, outline the hematoma to monitor, and pressure should be held until an intervention can occur. Consider anticoagulant and antiplatelet therapy.

Hope this helps you some!

Nellie Nurse · Feb 26, 2015

Thanks for the reply. The hematoma was too large to mark; extending into the groin and thigh. It was a critical situation. Unfortunately the SWAT nurse present, the one that we look to as a guide for interventions in these situations, gave poor advice and did not recommend continuation of holding pressure. Now that I have had several days to process the scenario, I realize how bad that advice was. At the time I felt like we should be holding pressure but when you have someone with more experience telling you different it makes one question themselves. This event has been a great learning opportunity for me and in the future I will not be so hesitant of what should be done.

thewandereRN · Feb 27, 2015

I can completely relate. Our jobs can be terrifying at times when we are unsure of what the right answer is. Trust your gut, and learn from your and others mistakes.... Thoses are two major things I've learned in my critical care experience.

Michi66 · Feb 27, 2015

We always hold pressure immediately and then call cath lab to request an RN to come up and assist with holding manual pressure (for hematomas and external bleeds). The cath lab RNs seem to hold pressure on the insertion site. In one incidence, the hematoma continued to grow (they did mark it somehow, although I was not there to see how) even after a femstop was used (I think they were suspecting a laceration as with your patient). Some online research also says to massage the hematoma to dissipate the blood or else it can take up to 6 months to be reabsorbed (if it's a big one), but I'm sure achieving hemastasis is first priority.

michlynn, BSN, RN · Feb 28, 2015

Typically if we have a hematoma you can feel it and we hold pressure to the site until it starts to soften or we'll stick a fem stop or a clamp on there depending on what the doc wants. I've personally never had a patient that needed continuous pressure for a pseudo if the hematoma site has softened up. Most of the time if the patient is hemodynamically stable they won't go to the OR until the following day or one of our cardiologists will take them back to the cath lab and inject thrombin to stop the bleeding. I guess it all depends on the severity of the bleed.

nursej22, MSN, RN · Mar 3, 2015

Every cardiologist accesses the artery at a different angle, some punctures are almost straight down, but most are slightly caudal and medial. I agree with a PP, pressure should be about 2 finger-widths above. But with a big hematoma, you just keep pushing until it stops growing, and continue pressure until a CT is done. And I've seen bleeding/hematomas occur retrograde and had to apply pressure below the puncture. Scary stuff!

A torn artery needs to be repaired ASAP, I've known patients to exsanguinate when they weren't. On the other hand, a pseudoaneurysm after a normal sheath removal can often wait and is injected with thrombin.

dah doh, BSN, RN · Mar 22, 2015

The ones that can't follow instructions & bend or move too much, the first time they get OOB after they are past the designated bed rest period, or just bad luck! I've had them all! So frustrating! Your facility should have a policy & the md should be notified.

Usually we hold manual pressure 2 fingers above & 1 finger medial of the puncture site or apply a femo-stop. Visible hematomas and bruising should be marked/outlined in permanent marker & checked at frequent intervals. Check pulses & circulation & vital signs & pain level at frequent intervals. Labs and scans may be ordered depending on symptoms. If the hematoma is fresh, it can be massaged. If the bleeding is really bad, the patient goes to surgery for repair or to interventional radiology for embolization.

canned_bread · May 6, 2015

Great questions, and just so you know, I reckon you should ask the cath lab to do an inservice in response to this. I am sure they would love to.

Yes - continuous manual pressure on the area. Keep checking for pedal pulses as you apply pressure. If you get tired, get someone else to help you. You should feel the pulse beneath your hands. You may need to give analgesia to the patient as these are very painful (that's one of the indicators that there is a haematoma).

You hold pressure over the puncture site and a bit proximal. The sheeth goes into the patients groin at a side angle, so the actual puncture of the vessel is a bit proximal. So on the site and up about an inch as well. It's about the width of your hand so it works well. :)

And I am serious about asking the cath lab, I am sure they would love to provide some education! I know we would!

Nursing considerations are BP, pulse, fluid bolus (good that you did that), and another IV (great that you did that!). Pain is a big issue, and also I would have the patient flat on their back and tell them not to lift there head. Which they should be doing anyway. I would make sure pedal pulses and the peripheries of that leg are still looking good (big red alarm if anything changes!). If the haematoma is enlarging under your hands it may be time to use something like a fem-stop that can go above the patients BP when your hands cannot. Try to avoid having the person who is holding the groin alone, or at least have someone in close proximity if things become out of control. Vaso-vagals can happen too. So I have patient on cardiac monitoring, 2 minutely non-invasive BP or 1 minutely if the BP is not looking good, fluids running full bore, and I chat to the patient as I gain control and make them smile. I also would expect the ward to call the cath lab for advice and an extra set of hands.

Also, a full bladder can put pressure on the groin area helping it to pop that clot. If the patient needs to pee, let them pee after these cases. For women, hold their groin as they hop onto the bed pan, and for men, they are easy. :) And no, dear patient, you cannot get out of bed or sit up to pee!