What is the management approach for an elderly male patient presenting with a suspected hematoma in the psoas muscle?

Management of Suspected Psoas Hematoma in an Elderly Male

For an elderly male with suspected psoas hematoma on imaging, immediately obtain CT abdomen and pelvis with IV contrast to confirm the diagnosis, assess for active bleeding, and determine hematoma size, followed by urgent reversal of any anticoagulation and conservative management in most cases. 1

Immediate Diagnostic Confirmation

CT with IV contrast or CT angiography (CTA) is the diagnostic test of choice for suspected retroperitoneal/psoas hematoma, providing critical information about hematoma size, active extravasation, and underlying vascular abnormalities. 1 The ACR Appropriateness Criteria specifically designate CT abdomen/pelvis with IV contrast or CTA as "usually appropriate" for initial imaging of clinically suspected retroperitoneal bleed. 1

• CT angiography can identify active arterial bleeding (contrast extravasation), which appears as areas of active hemorrhage requiring potential intervention. 1
• The imaging will differentiate acute from chronic blood and characterize the extent of the hematoma. 1
• CT is superior to ultrasound for retroperitoneal evaluation, as US has limited ability to assess the entire retroperitoneum and detect smaller volumes of blood. 1

Critical Initial Assessment

Check Anticoagulation Status Immediately

Obtain stat INR, PT/PTT, complete blood count with platelets, and comprehensive metabolic panel upon presentation. 2, 3

• If patient is on warfarin with INR ≥2.0: Administer 4-factor prothrombin complex concentrate (PCC) 25-50 IU/kg based on INR and body weight, plus intravenous vitamin K 5-10 mg to target INR <1.5. 2
• If on novel oral anticoagulants (NOACs): Use andexanet alfa for factor Xa inhibitors if available; if unavailable, use PCC. 3
• Discontinue anticoagulation immediately upon diagnosis of psoas hematoma. 2, 4

Assess Hemodynamic Stability

• Monitor vital signs closely for hypotension and tachycardia indicating ongoing hemorrhage. 4, 5
• Serial hemoglobin/hematocrit measurements every 4-6 hours initially to detect continued bleeding. 6, 7
• Type and crossmatch blood products in case transfusion becomes necessary. 5

Treatment Algorithm

Conservative Management (First-Line for Most Patients)

Conservative treatment is preferred over surgical drainage due to high risk of bleeding complications and mortality with intervention, particularly in elderly patients. 8, 4, 7, 9

Conservative management includes:

• Reversal of anticoagulation as detailed above 2, 4, 7
• Bed rest with hip flexion positioning to reduce tension on the psoas muscle 4
• Pain control with appropriate analgesics 4, 7
• Blood transfusion if hemoglobin drops significantly or patient becomes symptomatic 4, 5
• Serial imaging (repeat CT in 24-48 hours if clinically indicated) to assess for expansion 3

Interventional Management (For Active Bleeding)

If CT angiography demonstrates active arterial extravasation (contrast blush), proceed urgently to interventional radiology for arterial embolization. 5

• Lumbar artery bleeding is a common source and can be successfully treated with embolization, avoiding need for surgical intervention. 5
• Angiography with embolization is preferred over surgery when active bleeding source is identified, as it is less invasive and equally effective. 5
• This approach eliminates the high surgical risks in elderly, anticoagulated patients. 5

Surgical Drainage (Rarely Indicated)

Avoid surgical drainage in most cases due to:

• High risk of bleeding complications during the procedure 8
• Increased mortality risk, particularly in elderly patients 8
• Conservative management is generally successful 4, 7, 9

Monitoring for Complications

Lumbar Plexus Palsy

Assess for femoral nerve dysfunction (inability to extend knee, loss of patellar reflex, numbness over anterior thigh) as psoas hematomas can cause complete lumbar plexus palsy. 8, 4

• Neurological examination should include hip flexion strength, knee extension, sensation in femoral nerve distribution 8, 4
• Prognosis for neurological recovery is poor even with treatment; one case series showed no recovery at one-year follow-up. 8
• The neurological deficit develops insidiously, requiring high index of suspicion. 8

Compartment Syndrome Monitoring

Monitor serum creatine kinase (CK) levels as a marker for muscle damage, though this is more relevant for arterial thrombosis with revascularization. 6

• Check serum and urine myoglobin if significant muscle breakdown suspected 6
• Monitor renal function (creatinine, BUN) for acute kidney injury secondary to myoglobinuria 6

Common Pitfalls to Avoid

The diagnosis is easily missed in elderly patients due to:

• Non-specific symptoms (back pain, groin pain, leg weakness, anemia) that overlap with other common geriatric conditions 7
• Cognitive impairment compromising history reliability 7
• Multiple comorbidities that can explain symptoms 7
• Insidiously developing neurological deficits rather than acute presentation 8

Maintain high index of suspicion in any elderly patient on anticoagulation presenting with:

• Unexplained anemia 7
• Back, flank, or groin pain 4, 7
• Leg weakness or inability to walk 4
• Hip flexion pain 4

Do not delay CT imaging when psoas hematoma is in the differential diagnosis, as early diagnosis and prompt anticoagulation reversal improve functional outcomes. 4

Anticoagulation Resumption Decision

The decision to restart anticoagulation must balance thromboembolic risk against recurrent hemorrhage risk. 2

• Limited data suggest reinstitution of warfarin after 7-10 days may be safe in selected patients with high thromboembolic risk. 2
• Reassess the indication for anticoagulation and consider alternative strategies if possible. 3
• Outpatient follow-up for risk/benefit reassessment is essential. 3