What is the management approach for a rectus sheath hematoma?

Management of Rectus Sheath Hematoma

Initial Approach: Conservative Management is First-Line

Conservative management is the primary treatment for rectus sheath hematoma, with success rates of 86-100% even in large hematomas with hemodynamic compromise. 1, 2, 3

Immediate Stabilization

• Assess hemodynamic status immediately with continuous monitoring of vital signs and serial hemoglobin levels to detect ongoing bleeding 1
• Establish large-bore IV access (peripheral or central) in cases of significant bleeding to enable rapid fluid resuscitation and blood product administration 1
• Administer high FiO2 if significant blood loss or hemodynamic instability is present 1
• Obtain baseline labs: complete blood count, coagulation profile (PT/INR, aPTT), and type and crossmatch 1

Conservative Treatment Protocol

Hemostatic Measures

• Administer hemostatic agents: tranexamic acid and carbazochrome to control bleeding expansion 1, 4
• Apply direct compression to the hematoma site when feasible 1
• Reverse anticoagulation when appropriate:
  • For warfarin: administer vitamin K1 and fresh frozen plasma to normalize INR 2
  • For direct oral anticoagulants: use specific reversal agents based on the agent used 1
  • Note: 69% of RSH patients are on anticoagulation with mean INR of 2.6 3

Supportive Care

• Transfuse packed red blood cells for symptomatic anemia or hemodynamic instability; all type III (severe) hematomas required transfusion in one series 2
• Provide adequate analgesia for pain control 1
• Monitor for complications: abdominal compartment syndrome, multiorgan dysfunction, and continued bleeding 5

Diagnostic Confirmation

• CT abdomen/pelvis is the gold standard with 100% sensitivity, showing hematoma location, size, and active extravasation 2, 3
• Ultrasound has 75% sensitivity (9/12 cases in one series) and is operator-dependent 2
• CT was used in 83% of cases in the largest series and should be obtained to confirm diagnosis and guide management 3

Indications for Invasive Intervention

Surgical evacuation or endovascular embolization is reserved for failed conservative management only 1

Specific indications include:

• Hemodynamic instability despite aggressive resuscitation 3
• Continued bleeding with falling hemoglobin despite reversal of coagulopathy 5
• Abdominal compartment syndrome 5

Only 7.9% of patients required surgery or embolization in the largest series, with mortality of 1.6% 3

Important Clinical Pearls

Risk Factors to Recognize

• Female sex (64%), older age (mean 68 years), anticoagulation (69%), and cough/trauma (48%) are the key risk factors 3
• Classic triad: acute abdominal pain (84%), infraumbilical mass (63%), and anemia 2, 3

Common Pitfall

• Avoid unnecessary laparotomy: Early CT diagnosis prevents exploratory surgery in stable patients 2, 3
• One older series advocated surgery for all cases, but this approach is outdated; modern evidence strongly supports conservative management even for large hematomas 6

Resuming Anticoagulation

• RSH is not a contraindication to resuming anticoagulation once the hematoma is adequately managed and the patient returns to clinical baseline 5
• Timing should be individualized based on hematoma stability and indication for anticoagulation

Prevention

• Use proper technique during abdominal paracentesis to avoid injury to the inferior epigastric arteries, which are the usual bleeding source 1, 6