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Spontaneous rectus sheath hematoma in the elderly
Visual Journal of Emergency Medicine 10 (2018) 5–6
Contents lists available at ScienceDirect
Visual Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/visj
Visual Case Discussion
Spontaneous rectus sheath hematoma in the elderly
MARK
⁎
Joaquín Valle Alonso , Islam Farhad, Peter Swallow Department of Emergency Medicine, Royal Bournemouth Hospital, Dorset, UK
A R T I C L E I N F O Keywords: Rectus sheath hematoma RUSH POCUS ultrasound
A 74-year-old female patient with several comorbidities, including atrial fibrillation, congestive heart failure and COPD, presents to the emergency department brought by ambulance with increasing shortness of breath at rest. The patient had been recently discharged from the Hospital after an episode of COPD exacerbation and was on current treatment with doxycycline. She was anticoagulated with Warfarin. On examination, her temperature was 37.5 °C, blood pressure 85/ 45 mmHg, pulse rate 110 beats/min, and respiratory rate 27 breaths/min. The auscultation of the thorax revealed bilateral wheezing. The abdominal examination revealed an ecchymosis area in the periumbilical and right lower quadrant, tender on palpation. The exam
Fig. 1. POCUS Ultrasound of the abdomen shows showed a mass to the right of midline (arrows), consistent with hematoma of the recuts sheath.
⁎
Corresponding author. E-mail address: [email protected] (J.V. Alonso).
http://dx.doi.org/10.1016/j.visj.2017.07.012 Received 26 June 2017; Received in revised form 10 July 2017; Accepted 16 July 2017 2405-4690/ © 2017 Elsevier Inc. All rights reserved.
was difficult due to patient's obesity (BMI = 38.2) and no mass was palpable during examination. Initially the patient was treated as suspected sepsis with IV antibiotics and fluids. Laboratory findings revealed a significant drop in hemoglobin in a week interval from 11.1 g/dl to 7.4 g/dl with INR of 8.45. A Rapid Ultrasound for Shock and Hypotension (RUSH Exam) was performed. In the abdominal exam, the scanning of the abdominal aorta for AAA was normal; no free fluid was detected, however in the tenderness area of the abdomen using a low-frequency probe demonstrated a large complex fluid collection in the lower abdominal wall [1–2] (Fig. 1). An abdominal
Fig. 2. CT of the abdomen. There is a large right rectus sheath hematoma (arrows) which extends from just above the level of the umbilicus to the groin. Maximum dimensions are 21 cm (CC) by 7 cm (transverse) by 5.8 cm (AP).
Visual Journal of Emergency Medicine 10 (2018) 5–6
J.V. Alonso et al.
a. b. c. d. e.
CT was requested to confirm diagnosis (Fig. 2). RBC transfusion was initiated and octaplex (prothrombin complex concentrate) was administered to correct coagulopathy [3]. Appendix A. Supplementary material
IV fluids Platelet transfusion RBC transfusion Reversal of coagulopathy Surgical management
Answers
Supplementary data associated with this article can be found in the online version at doi:10.1016/j.visj.2017.07.012.
1. CT. Explanation: The best diagnostic modality to evaluate a suspected RSH is an abdominal computerized tomography (CT) scan, which is more specific than ultrasonography. (Abdom Imaging 1996;21:62.) Sonographic findings are nonspecific in some cases, and can mimic abdominal wall tumors and inflammatory diseases. (Am J Roentgenol 2007;188[6]:W497.) Digital subtraction angiography is the most useful imaging technique to identify active bleeding. It provides information about the number of bleeding sites and their exact location. (Am J Roentgenol 2007;188[6]:W497.) 2. Reversal of coagulopathy. Explanation: Timely reversal of coagulopathy is the most important aspect of management. Otherwise, management is usually conservative as the natural course of this problem is self-limiting. RBC transfusion is recommended in the presence of hemodynamic compromise or significant fall in hemoglobin. Invasive procedures or surgery are rarely needed for securing hemostasis and stabilizing hemodynamics. Surgical management is associated with significant morbidity due to the advanced age and multiple co-morbidities in these patients. Thus, it is reserved for the most severe cases.
References 1. Gallego A Moreno, Aguayo JL, Flores B, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath hematoma. Br J Surg. 1997;84:1295–1297. 2. Shokoohi H, Boniface K, Taheri M Reza, Pourmand A. Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography. Can J Emerg Med. 2013;15(2):119–122. 3. Smithson A, Ruiz J, Perello R, et al. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med. 2013;24(6):579–582.
Questions 1. What is the best diagnostic modality to evaluate suspected RSH? a. Abdomen X-ray b. Ultrasound c. CT d. MRI e. Digital angiography 2. What is the most important aspect of management in this patient?
6
Contents lists available at ScienceDirect
Visual Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/visj
Visual Case Discussion
Spontaneous rectus sheath hematoma in the elderly
MARK
⁎
Joaquín Valle Alonso , Islam Farhad, Peter Swallow Department of Emergency Medicine, Royal Bournemouth Hospital, Dorset, UK
A R T I C L E I N F O Keywords: Rectus sheath hematoma RUSH POCUS ultrasound
A 74-year-old female patient with several comorbidities, including atrial fibrillation, congestive heart failure and COPD, presents to the emergency department brought by ambulance with increasing shortness of breath at rest. The patient had been recently discharged from the Hospital after an episode of COPD exacerbation and was on current treatment with doxycycline. She was anticoagulated with Warfarin. On examination, her temperature was 37.5 °C, blood pressure 85/ 45 mmHg, pulse rate 110 beats/min, and respiratory rate 27 breaths/min. The auscultation of the thorax revealed bilateral wheezing. The abdominal examination revealed an ecchymosis area in the periumbilical and right lower quadrant, tender on palpation. The exam
Fig. 1. POCUS Ultrasound of the abdomen shows showed a mass to the right of midline (arrows), consistent with hematoma of the recuts sheath.
⁎
Corresponding author. E-mail address: [email protected] (J.V. Alonso).
http://dx.doi.org/10.1016/j.visj.2017.07.012 Received 26 June 2017; Received in revised form 10 July 2017; Accepted 16 July 2017 2405-4690/ © 2017 Elsevier Inc. All rights reserved.
was difficult due to patient's obesity (BMI = 38.2) and no mass was palpable during examination. Initially the patient was treated as suspected sepsis with IV antibiotics and fluids. Laboratory findings revealed a significant drop in hemoglobin in a week interval from 11.1 g/dl to 7.4 g/dl with INR of 8.45. A Rapid Ultrasound for Shock and Hypotension (RUSH Exam) was performed. In the abdominal exam, the scanning of the abdominal aorta for AAA was normal; no free fluid was detected, however in the tenderness area of the abdomen using a low-frequency probe demonstrated a large complex fluid collection in the lower abdominal wall [1–2] (Fig. 1). An abdominal
Fig. 2. CT of the abdomen. There is a large right rectus sheath hematoma (arrows) which extends from just above the level of the umbilicus to the groin. Maximum dimensions are 21 cm (CC) by 7 cm (transverse) by 5.8 cm (AP).
Visual Journal of Emergency Medicine 10 (2018) 5–6
J.V. Alonso et al.
a. b. c. d. e.
CT was requested to confirm diagnosis (Fig. 2). RBC transfusion was initiated and octaplex (prothrombin complex concentrate) was administered to correct coagulopathy [3]. Appendix A. Supplementary material
IV fluids Platelet transfusion RBC transfusion Reversal of coagulopathy Surgical management
Answers
Supplementary data associated with this article can be found in the online version at doi:10.1016/j.visj.2017.07.012.
1. CT. Explanation: The best diagnostic modality to evaluate a suspected RSH is an abdominal computerized tomography (CT) scan, which is more specific than ultrasonography. (Abdom Imaging 1996;21:62.) Sonographic findings are nonspecific in some cases, and can mimic abdominal wall tumors and inflammatory diseases. (Am J Roentgenol 2007;188[6]:W497.) Digital subtraction angiography is the most useful imaging technique to identify active bleeding. It provides information about the number of bleeding sites and their exact location. (Am J Roentgenol 2007;188[6]:W497.) 2. Reversal of coagulopathy. Explanation: Timely reversal of coagulopathy is the most important aspect of management. Otherwise, management is usually conservative as the natural course of this problem is self-limiting. RBC transfusion is recommended in the presence of hemodynamic compromise or significant fall in hemoglobin. Invasive procedures or surgery are rarely needed for securing hemostasis and stabilizing hemodynamics. Surgical management is associated with significant morbidity due to the advanced age and multiple co-morbidities in these patients. Thus, it is reserved for the most severe cases.
References 1. Gallego A Moreno, Aguayo JL, Flores B, et al. Ultrasonography and computed tomography reduce unnecessary surgery in abdominal rectus sheath hematoma. Br J Surg. 1997;84:1295–1297. 2. Shokoohi H, Boniface K, Taheri M Reza, Pourmand A. Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography. Can J Emerg Med. 2013;15(2):119–122. 3. Smithson A, Ruiz J, Perello R, et al. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med. 2013;24(6):579–582.
Questions 1. What is the best diagnostic modality to evaluate suspected RSH? a. Abdomen X-ray b. Ultrasound c. CT d. MRI e. Digital angiography 2. What is the most important aspect of management in this patient?
6