What is the management approach for a patient with a psoas hematoma?

Management of Psoas Hematoma

The management of psoas hematoma should be primarily conservative in hemodynamically stable patients, with close monitoring for neurological complications, while surgical intervention should be reserved for cases with hemodynamic instability, expanding hematoma, or severe neurological deficits that fail to improve with conservative measures. 1, 2, 3

Diagnosis

• CT scan with IV contrast is the preferred imaging modality for diagnosing suspected retroperitoneal bleeding, including psoas hematoma, as it can accurately identify the location, size, and potential source of bleeding 1
• MRI can be useful for differentiating between blood and underlying neoplasm, and for characterizing bleeding acuity by identifying acute versus chronic blood 1
• Clinical presentation may include flank pain, dropping hemoglobin, and femoral nerve palsy symptoms (weakness, numbness in anterior thigh) 2, 4
• In elderly patients, diagnosis can be challenging due to nonspecific symptoms that may overlap with other conditions 4

Initial Management

For Hemodynamically Stable Patients

• Conservative management is the first-line approach for stable patients with psoas hematoma 2, 3
• Discontinue anticoagulation therapy if present, and consider reversal agents based on the specific anticoagulant used 4
• Provide adequate analgesia for pain control 5
• Monitor hemoglobin levels regularly to assess for continued bleeding 1
• Apply the principles of rest, ice, compression, and elevation (RICE) to limit further bleeding and reduce inflammation 5

For Hemodynamically Unstable Patients

• Secure large-bore intravenous access (8-Fr central access is ideal in adults) 1
• Administer high FiO2 and actively warm the patient and all transfused fluids 1
• Obtain baseline blood tests including full blood count, coagulation studies (PT, aPTT, fibrinogen), and cross-match 1
• Initiate blood product resuscitation with warmed blood and blood components 1
• Consider invasive blood pressure monitoring for patients with significant comorbidities 1

Specific Treatment Approaches

Conservative Management

• Serial imaging (CT or ultrasound) to monitor hematoma size and resolution 2
• Correction of coagulopathy if present 6
• Physical therapy to maintain muscle function, particularly if femoral nerve palsy is present 6
• Close neurological monitoring for signs of femoral nerve compression or lumbar plexus involvement 7

Interventional Approaches

• Ultrasound-guided aspiration may be considered for large hematomas causing significant pain or functional impairment 5
• Percutaneous drainage can be attempted for accessible collections that are causing significant symptoms 1
• Arterial embolization should be considered if active bleeding is identified on imaging 1

Surgical Management

• Surgery should be reserved for cases with:
  • Hemodynamic instability despite resuscitation 1
  • Expanding hematoma with compression of vital structures 6
  • Severe or progressive neurological deficits that fail to improve with conservative measures 2, 6
• Surgical evacuation relieves pain, allows for earlier physiotherapy, and may lead to faster recovery of femoral nerve function compared to conservative management in selected cases 6

Monitoring and Follow-up

• Regular assessment of neurological function, particularly femoral nerve function 7
• Serial hemoglobin measurements to detect ongoing bleeding 1
• Follow-up imaging to confirm resolution of the hematoma 2
• Once bleeding is controlled, standard venous thromboprophylaxis should be commenced as patients rapidly develop a prothrombotic state 1

Pitfalls and Caveats

• Delayed diagnosis is common, especially in elderly patients with multiple comorbidities or cognitive impairment 4
• Femoral nerve palsy may develop late, even after initial stabilization 2
• Complete neurological recovery is not guaranteed, particularly in elderly patients or with large hematomas 7
• Rushing to drain iliopsoas hematomas in case of femoral nerve palsy might not always be the ideal option; monitoring patient response to conservative management may be appropriate 2
• The approach to iliopsoas hematoma remains somewhat controversial, with the decision between surgical and conservative management depending on multiple factors including patient hemodynamic status, progression of collection, and severity of femoral nerve palsy 2