How should an older anticoagulated patient with acute abdominal pain, a tender abdominal wall mass, hypotension, tachycardia, and dropping hemoglobin be evaluated and managed for suspected rectus sheath hematoma in the emergency department?

Emergency Department Management of Rectus Sheath Hematoma in Anticoagulated Elderly Patients

In an anticoagulated elderly patient presenting with acute abdominal pain, tender abdominal wall mass, hypotension, tachycardia, and dropping hemoglobin, immediately obtain CT imaging to confirm rectus sheath hematoma, secure large-bore IV access, reverse anticoagulation with specific agents, and initiate conservative management with hemostatic agents and blood transfusion as needed. 1, 2

Immediate Stabilization and Assessment

Hemodynamic Management

• Secure large-bore IV access immediately (preferably two 18-gauge or larger peripheral lines) to enable rapid fluid resuscitation and blood product administration in this hemodynamically unstable patient 1
• Administer high FiO2 to maintain adequate oxygenation given significant blood loss 1
• Avoid routine vasopressor use in hemorrhagic hypotension, as this represents hypovolemic shock requiring volume resuscitation, not vasopressor support 3
• Monitor vital signs continuously and assess for signs of ongoing bleeding including worsening hypotension, tachycardia progression, or altered mental status 1

Critical Laboratory Studies

• Obtain complete blood count, coagulation profile (PT, INR, aPTT), type and crossmatch immediately 3, 1
• For patients on warfarin, PT/INR is the most reliable test to assess clinically relevant anticoagulation exposure 3
• For patients on DOACs, obtain anti-Xa levels if available, though quantitative DOAC assays may not be immediately accessible 3
• Serial hemoglobin/hematocrit measurements every 6-12 hours until bleeding controlled and values stabilize 4
• A hematocrit drop >5-6% absolute indicates significant ongoing bleeding 3

Diagnostic Imaging

CT Abdomen as Gold Standard

• CT scan is the examination of choice and should be performed urgently to confirm diagnosis, assess hematoma size and location, and rule out intraperitoneal rupture 5, 2
• CT demonstrates 100% sensitivity for rectus sheath hematoma compared to 75% for ultrasound 5, 6
• CT with contrast may identify active arterial extravasation requiring embolization 1
• Look specifically for Type II (moderate, confined to rectus muscle) versus Type III (severe, extending beyond rectus sheath or bilateral) hematomas, as Type III requires more aggressive management 2

Ultrasound Limitations

• Ultrasound can be used as initial screening but misses approximately 25% of cases 5, 6
• Ultrasound is operator-dependent and less reliable for detecting free intraperitoneal blood or defining hematoma extent 6

Anticoagulation Reversal

For Warfarin (Vitamin K Antagonists)

• Administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5 mg IV vitamin K immediately for life-threatening bleeding in critical organs (abdominal bleeding qualifies) 3
• Target INR <1.5 before any surgical intervention 3
• Administer additional doses of 4F-PCC if INR remains >1.5 3
• Fresh frozen plasma should only be used if 4F-PCC is unavailable, as it is less effective 3
• Do NOT use recombinant factor VIIa as first-line reversal agent 3

For Direct Oral Anticoagulants (DOACs)

• For dabigatran: Administer idarucizumab 5 g IV immediately for uncontrolled life-threatening bleeding 3
• If idarucizumab unavailable, give activated prothrombin complex concentrates (APCC) 50 units/kg IV 3
• For rivaroxaban or apixaban: Administer andexanet alfa (400 mg IV bolus over 15 min followed by 480 mg infusion over 2 hours for low dose, or 800 mg bolus over 30 min followed by 960 mg over 2 hours for high dose) 3
• If andexanet alfa unavailable, give 2000 units of 4F-PCC 3
• Assess DOAC levels before reversal if quantitative tests available, as reversal carries thromboembolic risk 3

Conservative Management Protocol

Hemostatic Agents

• Administer tranexamic acid and carbazochrome to control bleeding expansion 1, 7
• These agents have demonstrated effectiveness in spontaneous rectus sheath hematoma even in elderly patients 7

Blood Product Transfusion

• Transfuse packed red blood cells to maintain hemoglobin >7-8 g/dL in hemodynamically unstable patients 2
• All Type III hematomas (large, extending beyond rectus sheath) typically require blood transfusion 2
• Continue transfusion support until hemoglobin stabilizes and vital signs normalize 5, 2

Direct Compression

• Apply manual compression to the hematoma site if accessible, though effectiveness is limited for deep rectus sheath hematomas 1

Monitoring During Conservative Management

• Serial hemoglobin checks every 6-12 hours 4
• Continuous vital sign monitoring for first 24-48 hours 1
• Repeat CT scan at 3-5 days to document hematoma reduction and ensure no expansion 7, 2
• Monitor for abdominal compartment syndrome (bladder pressure >20 mmHg, oliguria, respiratory compromise) 8

Indications for Interventional/Surgical Management

Angiography and Embolization

• Perform CT angiography if active arterial extravasation identified on initial CT 1
• Angiographic embolization is first-line invasive therapy for ongoing bleeding despite reversal and conservative measures 1
• Target inferior epigastric artery or its branches, which are most commonly involved 1

Surgical Evacuation

• Reserve surgery only for failed embolization or when embolization is not available 1
• Surgery indicated for intraperitoneal rupture with free blood detected on CT 6, 2
• Surgical intervention associated with shorter hospital stay and reduced analgesic requirements, but should not be first-line given success of conservative management 6

Critical Pitfalls to Avoid

Diagnostic Errors

• Do not rely on single hematocrit measurement as it may not reflect acute blood loss in the first few hours 4
• Do not dismiss the diagnosis in patients without trauma history—spontaneous RSH occurs, especially in elderly with atherosclerotic vessels 7, 5
• Do not assume normal coagulation studies rule out anticoagulant effect—elderly patients bleed more even with therapeutic INR due to age-related vascular fragility 4

Management Errors

• Do not perform unnecessary laparotomy—RSH mimics acute surgical abdomen but 80-90% can be managed conservatively 5, 2
• Do not restart anticoagulation until hematoma stabilized and patient returned to clinical baseline, typically 5-7 days minimum 8, 5
• Do not use vasopressors for hemorrhagic hypotension—this worsens tissue perfusion and does not address the underlying hypovolemia 3

Anticoagulation Reversal Errors

• Do not delay reversal waiting for coagulation studies in unstable patients—clinical presentation of hypotension and dropping hemoglobin warrants immediate reversal 3
• Do not use FFP as first-line for warfarin reversal when 4F-PCC available—it is significantly less effective 3

Expected Clinical Course

• With appropriate conservative management, hemoglobin should stabilize within 24-48 hours 2
• Symptoms typically improve significantly by day 3-4 7
• Follow-up CT at 4-5 days should show hematoma size reduction 7
• Mean hospital stay ranges 6-14 days depending on hematoma severity and comorbidities 7, 5
• Mortality risk is 4-25% in elderly patients with significant comorbidities, emphasizing need for aggressive early management 5