Management of Rectus Sheath Hematoma
Most rectus sheath hematomas (86-90%) should be managed conservatively with hemodynamic monitoring, reversal of anticoagulation when appropriate, blood transfusion as needed, and supportive care—surgery or interventional radiology is reserved only for hemodynamically unstable patients who fail conservative measures. 1, 2, 3
Initial Assessment and Hemodynamic Stabilization
Immediate priorities focus on detecting ongoing bleeding and preventing hemodynamic collapse:
Monitor vital signs continuously and obtain serial hemoglobin measurements to detect active hemorrhage, as rectus sheath hematomas can cause significant blood loss requiring transfusion in up to 50% of type III hematomas 1, 2
Establish large-bore intravenous access (preferably two peripheral IVs or central access if significant bleeding is suspected) to enable rapid fluid resuscitation and blood product administration 1
Obtain baseline laboratory studies immediately: complete blood count, coagulation profile (PT/INR, aPTT), type and crossmatch for potential transfusion 1, 3
Administer supplemental oxygen in patients with significant blood loss or hemodynamic instability to maintain adequate tissue oxygenation 1
Diagnostic Confirmation
CT scan of the abdomen and pelvis is the diagnostic modality of choice with 100% sensitivity for establishing the diagnosis and should be obtained in all suspected cases 2, 3. CT imaging allows classification of hematoma type (I, II, or III) which guides prognosis and transfusion requirements 2.
Conservative Management (First-Line for Most Patients)
Conservative treatment is successful in 86-90% of cases and should be the initial approach for hemodynamically stable patients: 2, 3
Reverse anticoagulation immediately if the patient is on warfarin, direct oral anticoagulants, or heparin—use specific reversal agents based on the anticoagulant (vitamin K and/or prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1, 4
Transfuse packed red blood cells to maintain hemoglobin >7-9 g/dL, with higher targets for patients with cardiovascular disease or ongoing bleeding—type III hematomas universally require transfusion 2, 3
Apply local compression to the hematoma site when feasible to tamponade bleeding 1
Administer hemostatic agents such as tranexamic acid (10-15 mg/kg loading dose followed by 1-5 mg/kg/h infusion) and carbazochrome to control bleeding expansion 5, 6
Provide adequate analgesia for pain control while monitoring for signs of expanding hematoma or hemodynamic deterioration 2
Indications for Interventional or Surgical Management
Escalate to invasive management only when conservative measures fail:
Angiographic embolization is the preferred invasive approach for patients with ongoing hemodynamic instability despite adequate resuscitation and reversal of anticoagulation 1, 3
Surgical evacuation is indicated only when embolization fails or is not available, or in cases of abdominal compartment syndrome 1, 2
Approximately 8% of patients require surgery or endovascular intervention, with mortality from rectus sheath hematoma being rare (1.6%) when appropriately managed 3
Special Considerations and Risk Factors
Recognize high-risk patients who require closer monitoring:
Elderly patients (mean age 68 years), females (64% of cases), and those on anticoagulation (69% of cases) are at highest risk 3
Patients with type III hematomas (extending below the arcuate line with potential for larger blood loss) universally require transfusion and warrant ICU-level monitoring 2
Cough or minor abdominal trauma precedes 29-48% of cases, making this a critical historical feature 3
Resumption of Anticoagulation
Anticoagulation can be safely resumed once the hematoma is stable and the patient has returned to clinical baseline—rectus sheath hematoma is not a permanent contraindication to anticoagulation 4. However, in patients who develop deep venous thrombosis during the acute phase, consider inferior vena cava filter placement rather than therapeutic anticoagulation to avoid rebleeding 7.
Prevention Strategies
Minimize risk in high-risk patients through proper technique:
Use direct visualization during trocar insertion in laparoscopic surgery to avoid injury to the inferior epigastric arteries 2
Exercise caution with subcutaneous low-molecular-weight heparin injections in the abdominal wall, as this can cause severe rectus sheath hematoma 2
Avoid the inferior epigastric arteries during abdominal paracentesis by using proper landmarks 1