What are the treatment steps for psoas muscle hemorrhage?

Management of Psoas Muscle Hemorrhage

The management of psoas muscle hemorrhage requires immediate assessment of hemodynamic status, followed by appropriate imaging and targeted interventions based on bleeding severity, with surgical or angiographic intervention reserved for unstable patients. 1

Initial Assessment and Stabilization

• Hemodynamic evaluation:

  • Assess vital signs (heart rate, blood pressure, capillary refill, skin color, consciousness)
  • Look for signs of internal blood loss and visible external bleeding
  • If patient is conscious with palpable peripheral pulse, blood pressure is likely adequate 1

• Immediate interventions for unstable patients:

  • Control obvious bleeding points with direct pressure
  • Administer high FiO2
  • Establish large-bore IV access (peripheral or central)
  • Obtain baseline labs: CBC, PT, aPTT, Clauss fibrinogen, and cross-match 1
  • Begin fluid resuscitation with warmed blood products if needed
  • Target systolic BP of 80-100 mmHg until major bleeding is controlled (if no brain injury) 1

Diagnostic Imaging

• For hemodynamically stable patients:

  • CT scan with IV contrast is the diagnostic modality of choice 2
  • Allows rapid identification and measurement of the hematoma
  • Can identify associated injuries (e.g., vertebral fractures) 2

• For unstable patients:

  • FAST ultrasound to detect free fluid in the abdomen 1
  • If significant free intraabdominal fluid is present with hemodynamic instability, proceed to urgent surgery 1

Management Based on Severity

Conservative Management (Stable Patients)

• Most psoas hematomas can be managed non-operatively 2, 3
• Includes:
  • Bed rest
  • Pain control
  • Serial hemoglobin monitoring
  • Correction of any coagulopathy
  • Transfusion if needed based on hemodynamic status and hemoglobin levels

Interventional Management (Unstable or Deteriorating Patients)

• Angiographic embolization:

  • First-line intervention for active bleeding identified on CT scan
  • Particularly effective for arterial bleeding from lumbar segmental vessels 4

• Surgical intervention:

  • Indicated for:
    • Expanding hematomas causing neurological deficits (e.g., femoral nerve palsy) 5
    • Failure of conservative management with ongoing bleeding
    • Compartment syndrome
    • Infection of the hematoma
  • Surgical evacuation relieves pain and allows for earlier physiotherapy 5

Monitoring and Follow-up

• Admit to critical care for monitoring after treatment for massive hemorrhage 1
• Regular assessment of:
  • Vital signs
  • Hemoglobin and hematocrit
  • Coagulation parameters
  • Pain levels
  • Neurological status (particularly femoral nerve function)
• Repeat imaging to evaluate hematoma size if clinical deterioration occurs

Special Considerations

• Coagulopathy management:

  • If anticoagulant-related, reverse anticoagulation appropriately
  • Target fibrinogen levels >1.5 g/L and platelet count >75 × 10⁹/L 6
  • Consider tranexamic acid (10-15 mg/kg followed by infusion of 1-5 mg/kg/h) 1

• Thromboprophylaxis:

  • Initiate standard venous thromboprophylaxis as soon as bleeding is controlled 1
  • Consider temporary inferior vena cava filtration in high-risk cases

Common Pitfalls to Avoid

• Delayed diagnosis: Psoas hematoma may present with vague symptoms like back pain, groin pain, or femoral nerve palsy rather than obvious bleeding 2, 3
• Over-resuscitation: Aggressive fluid resuscitation to normalize blood pressure before bleeding control may worsen bleeding 1
• Missing associated injuries: Vertebral fractures or other abdominal injuries may coexist with psoas hematoma 2
• Failure to monitor for compartment syndrome: Large hematomas can cause pressure effects requiring surgical decompression