What is the management plan for an extraperitoneal (outside the peritoneal cavity) hematoma (blood clot)?

Management of Extraperitoneal Hematoma

The management of extraperitoneal hematoma should be guided by the patient's hemodynamic status, with hemodynamically unstable patients requiring immediate intervention through surgery or angioembolization, while stable patients can be managed non-operatively with close monitoring.

Initial Assessment and Diagnosis

• Diagnostic approach is determined by the patient's hemodynamic status 1
• For initial rapid assessment:
  • E-FAST (Extended Focused Assessment with Sonography for Trauma) is effective for detecting intra-abdominal free fluid 1
  • CT scan with intravenous contrast is the gold standard for hemodynamically stable patients 1

Management Algorithm Based on Hemodynamic Status

Hemodynamically Stable Patients

1. Non-operative management (NOM) is the treatment of choice 1

   • Serial clinical evaluations (physical exams and laboratory testing) to detect changes in clinical status
   • May require ICU admission for monitoring, especially with larger hematomas

2. Imaging follow-up

   • Consider follow-up CT scan to monitor hematoma size and resolution
   • Look for signs of active extravasation that might require intervention

3. Conservative measures

   • Correction of coagulopathy if present
   • Blood transfusion if needed for symptomatic anemia
   • Pain management
   • Early mobilization when stable 1
   • Early enteral feeding in the absence of contraindications 1

Hemodynamically Unstable Patients

1. Immediate intervention required 1

   • Surgery (laparotomy) OR
   • Angioembolization in selected situations

2. Specific interventions based on location and severity:

   • For large perirenal hematoma (>4 cm) with vascular contrast extravasation, immediate intervention with angioembolization or surgery is recommended 1
   • Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be used as a bridge to definitive procedures for hemorrhage control 1

3. Angiography and embolization

   • Highly effective for controlling arterial bleeding that cannot be controlled by other means 1
   • Particularly useful for spontaneous extraperitoneal hemorrhage with active extravasation 2, 3
   • Success rates are high, with angiographic cessation of bleeding achieved in most cases 3

Special Considerations

Anticoagulant-Related Hematomas

• Spontaneous extraperitoneal hemorrhage is a known complication of anticoagulation therapy 2, 4
• Management includes:
  • Correction of coagulopathy
  • Transcatheter arterial embolization (TAE) has been shown to be effective and safe when conservative treatment is insufficient 4
  • Enhanced CT has a supplementary role in detecting active bleeding that provides indication for angiographic therapy 4

Bladder-Related Extraperitoneal Injuries

• Uncomplicated extraperitoneal bladder injuries can be managed using urethral catheter drainage 1
• Catheter should remain in place for 2-3 weeks 1
• Follow-up cystography to confirm healing 1

Pitfalls and Caveats

1. Multiple bleeding sites are common in spontaneous extraperitoneal hemorrhage (61% of cases in one study) 3

2. Delayed hemorrhage without severe hemodynamic compromise may be managed with angioembolization 1

3. Laparoscopic approach may be considered in hemodynamically stable patients:

   • For diagnostic purposes when radiologic survey suggests diaphragmatic or hollow viscus injury
   • Later, to complete non-operative management 1

4. Avoid non-therapeutic laparotomy when possible, as it increases hospital length of stay and carries significant risk of complications 1

5. Consider contrast-enhanced CT in patients with large extraperitoneal hematomas to detect active bleeding that may benefit from angiographic therapy 4

By following this algorithm based on hemodynamic status and utilizing appropriate diagnostic and therapeutic modalities, mortality and morbidity from extraperitoneal hematomas can be minimized.