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

Management of Retroperitoneal Hematoma

Immediate Hemodynamic Assessment

Hemodynamically unstable patients require immediate operative intervention without imaging, while stable patients should undergo CT angiography (CTA) of the abdomen/pelvis with IV contrast as the diagnostic modality of choice. 1, 2

The critical first step is determining hemodynamic stability through vital signs assessment, signs of hypovolemia, and severity of ongoing blood loss. 1 Establish large-bore IV access immediately and initiate aggressive fluid resuscitation if any signs of instability are present. 1 Maintain body temperature above 36°C as hypothermia impairs clotting factor function. 1

Diagnostic Imaging Algorithm

For hemodynamically stable patients, CTA of the abdomen/pelvis with IV contrast is the gold standard imaging modality, detecting bleeding rates as slow as 0.3 mL/min and providing detailed vascular anatomy. 3, 1, 2 CTA identifies active extravasation, pseudoaneurysms, arteriovenous fistulas, hematoma size, and bleeding source. 1, 2

CT findings indicate acuity based on attenuation: high attenuation indicates acute bleeding, mixed attenuation suggests rebleeding, and low attenuation indicates subacute to chronic blood products. 1, 2

Common pitfall: Ultrasound is NOT appropriate for initial diagnosis due to limited acoustic windows and inability to evaluate the entire retroperitoneum reliably. 2 Plain radiography has low sensitivity and should not be used, as moderate-volume hematomas may not produce sufficient mass effect. 2

Treatment Algorithm Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Immediate operative intervention is mandatory for patients unresponsive to volume resuscitation. 1, 2
• Do not delay surgery for imaging. 1
• Pulsatile or expanding retroperitoneal hematoma discovered during laparotomy mandates exploration. 2
• Uncontrollable life-threatening hemorrhage with renal pedicle avulsion or renal vein lesion requires urgent operative intervention. 2

Hemodynamically Stable Patients with Active Bleeding on CTA

Super-selective angioembolization is the first-line treatment, achieving cessation of bleeding in nearly 100% of cases when active bleeding is identified on angiography. 1, 2

Indications for angioembolization include: 2

• Arterial contrast extravasation
• Pseudoaneurysms
• Arteriovenous fistula
• Non-self-limiting gross hematuria

Critical caveat: Blind angioembolization is NOT indicated in stable patients with negative angiography, regardless of arterial contrast extravasation on CT scan. 2 Angioembolization should be performed as selectively as possible to preserve organ function. 2

Hemodynamically Stable Patients without Active Bleeding

Conservative management with fluid resuscitation, correction of coagulopathy, and blood transfusion is appropriate. 4

Massive Transfusion Protocol

Transfuse packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio for massive hemorrhage. 1 Administer tranexamic acid 1g IV over 10 minutes within 1-3 hours of bleeding onset. 1

Goal-directed coagulation management: 1

• Administer fibrinogen concentrate 3-4g initially if fibrinogen is low, guided by viscoelastic monitoring
• Maintain platelet count above 50 × 10⁹/L

Special Clinical Scenarios

Pelvic Fracture-Associated Hematomas

These represent 55% of blunt trauma cases and require higher transfusion volumes. 1, 2 Apply pelvic binder in pre-hospital setting to limit life-threatening bleeding. 1

Penetrating Trauma

Requires exploration if not adequately studied preoperatively. 1, 2

Renal Injuries

Shattered kidney or pyelo-ureteral junction avulsion in stable patients does NOT mandate urgent surgical intervention. 1, 2 Urine extravasation alone is not an indication for operative management in the acute setting. 2 Devascularized kidney tissue causing refractory hypertension may require delayed nephrectomy if conservative management fails. 2

Anticoagulation-Related Bleeding

Anticoagulant therapy is a major cause of spontaneous retroperitoneal hemorrhage, particularly with excessive anticoagulation. 5 Reverse coagulopathy immediately. 4

Critical Pitfalls to Avoid

Delaying surgical intervention in unstable patients while pursuing imaging or conservative measures is a critical pitfall—early diagnosis within the first 5 hours significantly improves outcomes. 1, 2

Diagnosis can be delayed due to nonspecific signs: 1, 2, 5

• Diffuse abdominal pain (67.5% of cases)
• Back pain (21.3% of cases)
• Flank mass
• Suprainguinal tenderness and fullness (100% when present)
• Femoral neuropathy (36% when present)

Monitoring and Follow-up

Follow-up CT is appropriate to evaluate for rebleeding, changes in hematoma size, or complications such as infection and abscess formation. 2