Management of Rectus Sheath Hematoma
The management of rectus sheath hematoma should primarily be conservative, including hemodynamic stabilization, pain control, and correction of coagulopathy if present, with surgical intervention reserved only for cases with hemodynamic instability unresponsive to resuscitation or expanding hematomas causing abdominal compartment syndrome. 1, 2
Initial Assessment and Stabilization
- Immediate assessment of hemodynamic status with close monitoring of vital signs and hemoglobin levels to detect ongoing bleeding 3
- Secure adequate intravenous access, preferably with large-bore peripheral or central access in cases of significant bleeding 3
- Administer high FiO2 in patients with significant blood loss or hemodynamic instability 3
- Obtain baseline laboratory studies including complete blood count, coagulation profile (PT, aPTT, fibrinogen), and type and cross-match 3
Diagnostic Approach
- CT scan of the abdomen is the preferred diagnostic modality, with 83% of cases diagnosed this way 2
- Ultrasonography can be used as an initial screening tool, particularly in hemodynamically unstable patients who cannot be transported safely 4
- Clinical diagnosis should be suspected in patients with abdominal pain (84% of cases) and abdominal wall mass (63% of cases), especially with risk factors such as anticoagulation therapy (69% of cases) 2
Conservative Management
Bed rest and analgesia to minimize further bleeding and manage pain 5, 1
Discontinuation of anticoagulant therapy if present, which is a contributing factor in 69% of cases 2
Reversal of anticoagulation when appropriate:
Blood transfusion for patients with significant anemia or hemodynamic instability 4, 2
Consider hemostatic agents such as tranexamic acid to control bleeding, which has shown effectiveness in case reports 5
Compression of the hematoma site may be helpful in some cases 3
Monitoring and Follow-up
- Serial hemoglobin measurements to assess for continued bleeding 6
- Repeat imaging (ultrasound or CT) to monitor hematoma size in cases of clinical deterioration or suspected expansion 5
- ICU admission for patients with significant bleeding or hemodynamic instability 3
Indications for Invasive Management
- Hemodynamic instability despite adequate resuscitation 3
- Expanding hematoma with signs of abdominal compartment syndrome 1
- Failed conservative management with continued bleeding 6
Invasive Management Options
- Endovascular embolization of bleeding vessels is the preferred first-line invasive approach when conservative management fails 6, 2
- Surgical evacuation is indicated only in cases of:
- Failed embolization
- Abdominal compartment syndrome
- Infected hematoma
- Severe hemodynamic instability unresponsive to other measures 2
Special Considerations
- Patients on anticoagulation therapy require careful evaluation of the risks and benefits of reversing anticoagulation versus the risk of thrombotic events 1
- Anticoagulation can be safely resumed once the hematoma has stabilized and the patient has returned to clinical baseline 1
- Elderly patients and those with multiple comorbidities have higher morbidity and mortality rates, requiring more aggressive monitoring and earlier intervention 5, 2
Prevention Strategies
- Careful anticoagulation management, especially in high-risk patients (elderly, female sex, renal impairment) 2
- Management of conditions causing increased intra-abdominal pressure (chronic cough, constipation) 2
- Proper technique for abdominal paracentesis to avoid injury to the inferior epigastric arteries 3
Most rectus sheath hematomas (86%) can be successfully managed with conservative treatment alone 2, with only 7.9% requiring surgical or endovascular intervention and a mortality rate of 1.6% directly attributable to the hematoma 2.