What is the appropriate assessment and management for swelling of the sternum and right shoulder pain that began 24 hours after cardiac catheterisation?

Immediate Assessment for Vascular Injury and Hematoma

Sternal swelling and right shoulder pain 24 hours after cardiac catheterization requires urgent evaluation for vascular injury, particularly if right radial access was used, as this presentation is consistent with mediastinal or pectoral hematoma from vessel perforation along the catheter track.

Critical Initial Evaluation

Perform these assessments immediately:

• Vital signs: Look specifically for hypotension, tachycardia, or hemodynamic instability suggesting active bleeding
• Access site examination: Inspect the radial or femoral puncture site for hematoma, swelling, or pulsatile mass
• Chest wall inspection: Assess for visible swelling, ecchymosis, or asymmetry over the sternum and right pectoral region
• Vascular assessment: Check distal pulses, capillary refill, and limb perforation in the accessed extremity
• Pain characteristics: Determine if pain is localized to access site track, radiates along vessel course, or associated with swallowing (odynophagia suggests mediastinal involvement)

Diagnostic Imaging

Order CT chest with IV contrast immediately if the patient is hemodynamically stable 1. This is the primary diagnostic modality to identify:

• Mediastinal hematoma (particularly if odynophagia is present, suggesting retroesophageal bleeding)
• Pectoral muscle hematoma from axillary or subclavian branch perforation 2
• Vessel injury location and extent
• Presence of aberrant vascular anatomy (e.g., aberrant subclavian artery) 1

Obtain duplex ultrasonography of the access site and proximal vessels to evaluate for:

• Radial artery pseudoaneurysm (presents as pulsatile mass with localized pain) 3
• Active extravasation
• Arteriovenous fistula
• Vessel occlusion

Management Algorithm

If Hemodynamically Stable with Contained Hematoma:

1. Admit to monitored unit (ICU or step-down) for close observation 1
2. Serial hemoglobin checks every 4-6 hours for first 24 hours
3. Hold anticoagulation and antiplatelet agents temporarily if safe from cardiac standpoint
4. Conservative management with observation is appropriate for most contained hematomas that are not expanding 1
5. Pain management: Implement structured analgesic protocol using numeric rating scale (NRS 0-10), with goal of keeping pain <3 4

If Hemodynamically Unstable or Expanding Hematoma:

1. Activate vascular surgery consultation immediately
2. Type and cross-match blood products
3. Consider emergent angiography with potential for:
   • Coil embolization of bleeding vessel 2
   • Covered stent placement
   • Autologous blood clot injection for pseudoaneurysm

For Radial Artery Pseudoaneurysm:

Ultrasound-guided thrombin injection is first-line for symptomatic pseudoaneurysms >2 cm 3. Reserve surgical repair for:

• Failed thrombin injection
• Infected pseudoaneurysm
• Rapidly expanding lesions
• Skin compromise

Common Pitfalls to Avoid

• Do not dismiss shoulder pain as musculoskeletal without imaging—this can represent referred pain from mediastinal or vascular injury 5, 1
• Do not assume normal ECG and echocardiogram exclude vascular complications 1
• Do not delay imaging in patients with persistent or worsening symptoms beyond 24 hours post-procedure
• Do not restart full anticoagulation without confirming hemostasis and stable hematoma

Specific Considerations for Right Radial Access

Right radial access increases risk of injury to:

• Aberrant right subclavian artery (retroesophageal course causes odynophagia) 1
• Axillary artery branches (causes pectoral hematoma) 2
• Brachiocephalic vessels

CT angiography is essential to map vascular anatomy and identify injury location when right-sided symptoms occur 1.

Follow-up Management

Once stabilized:

• Repeat imaging in 48-72 hours if symptoms persist or worsen
• Gradual resumption of anticoagulation once bleeding controlled (typically 48-72 hours)
• Outpatient ultrasound surveillance at 2-4 weeks for pseudoaneurysms managed conservatively 3
• Physical therapy referral if shoulder pain persists beyond acute phase, as post-cardiac surgery shoulder pain can be moderately severe and disabling 5