What is the management of rectus sheath hematoma?

Management of Rectus Sheath Hematoma

Conservative management is the first-line approach for most cases of rectus sheath hematoma (RSH), with surgical intervention reserved only for cases with hemodynamic instability that fails to respond to supportive measures.

Initial Assessment and Classification

• Diagnosis is typically confirmed by CT scan, which is the examination of choice for RSH 1
• RSH should be suspected in patients presenting with:
  • Acute abdominal pain
  • Palpable infraumbilical mass
  • Anemic syndrome, especially in elderly patients on anticoagulation 1
• Classify RSH based on severity:
  • Type I: Contained within the muscle
  • Type II: Moderate hematoma between muscle and fascia
  • Type III: Severe hematoma extending into peritoneum and prevesical space

Conservative Management

First-line Treatment

1. Hemodynamic monitoring and support

   • IV fluid resuscitation if needed
   • Blood pressure and heart rate monitoring

2. Pain management

   • Multimodal analgesia including non-opioid analgesics 2
   • Regional anesthesia techniques may be considered for severe pain 2

3. Local measures

   • RICE protocol: Rest, Ice, Compression, Elevation 3
   • Apply cold therapy with compression to reduce bleeding and hematoma formation 3
   • Cold compression has been shown to reduce hematoma size by approximately 20 cm² over 180 minutes compared to compression alone 3

4. Anticoagulation management

   • Discontinue anticoagulant therapy if present 1, 4
   • Normalize coagulation parameters with:
     • Vitamin K1 administration
     • Fresh frozen plasma as needed 1, 4

5. Blood product support

   • Blood transfusion for all Type III hematomas and as needed for others 1
   • Target hemoglobin level of 70-90 g/L 3

6. Hemostatic agents

   • Consider tranexamic acid administration (within 3 hours of onset) 3, 5
   • Carbazochrome may also be effective in controlling expansion 5

Monitoring

• Serial hemoglobin/hematocrit measurements
• Repeat imaging (ultrasound or CT) to assess hematoma size
• Close observation for signs of hemodynamic instability
• Monitor for complications:
  • Abdominal compartment syndrome
  • Skin necrosis due to increased tissue pressure 3

Indications for Interventional or Surgical Management

• Hemodynamic instability despite adequate resuscitation 6
• Expanding hematoma with uncontrolled bleeding
• Development of abdominal compartment syndrome
• Signs of infection

Interventional Options

1. Arterial embolization

   • First-line interventional approach
   • Particularly useful for patients with identified bleeding vessel on CT angiography

2. Surgical evacuation

   • Reserved for cases failing conservative and interventional management
   • May be necessary in cases of infected hematoma

Prognosis and Follow-up

• Most patients can be managed successfully with conservative treatment 1
• Hospital stay averages 13-14 days for conservatively managed cases 4
• Follow-up imaging is recommended to ensure resolution
• Anticoagulation can be resumed once the hematoma has stabilized and the patient has returned to clinical baseline 7

Special Considerations

• Elderly patients and those with comorbidities have higher morbidity and mortality rates 5
• No specific prognostic risk factors have been identified to predict which patients will develop hemodynamic instability requiring operative intervention 6
• Early diagnosis is crucial to prevent unnecessary surgical intervention 4

Conservative management with close monitoring remains the cornerstone of RSH treatment, with most patients responding well to supportive care even with large hematomas 1.