What discharge precautions and red‑flag symptoms should a patient with a rectus sheath hematoma follow, including activity restriction, anticoagulation management, and when to return to the emergency department?

Discharge Precautions for Rectus Sheath Hematoma

Patients with rectus sheath hematoma managed conservatively should be discharged with strict instructions to return immediately for signs of hematoma expansion, hemodynamic instability, or compartment syndrome, with close follow-up within 24-48 hours.

Red-Flag Symptoms Requiring Immediate ED Return

Patients must return to the emergency department if they experience any of the following:

• Worsening or new abdominal pain, particularly increasing severity or change in character, as this may indicate hematoma expansion 1, 2
• Visible expansion of abdominal wall swelling or mass, suggesting ongoing bleeding 1, 3
• Lightheadedness, dizziness, or syncope, which may indicate hemodynamic compromise from continued blood loss 1
• Difficulty breathing or shortness of breath, as this can signal abdominal compartment syndrome or respiratory compromise 1
• Difficulty urinating or inability to void completely, which may indicate bladder compression from expanding hematoma 1
• Nausea, vomiting, or abdominal distension, particularly if progressive 1
• Signs of shock: rapid heart rate, low blood pressure, cold/clammy skin, confusion 1, 2

Activity Restrictions

• Strict bed rest for the first 48-72 hours after diagnosis, as physical activity can precipitate rebleeding 3, 4
• Avoid all strenuous activities, heavy lifting (>10 lbs), and Valsalva maneuvers (straining, coughing forcefully) for at least 2-4 weeks 5, 4
• No abdominal muscle straining or exercises until follow-up imaging confirms hematoma resolution 5
• Gradual return to normal activities only after clinical and radiographic improvement is documented 4

Anticoagulation Management

All anticoagulation and antiplatelet therapy must be held immediately upon diagnosis of rectus sheath hematoma, as 80.6% of cases occur in patients on these medications 4. The decision to restart anticoagulation requires careful risk-benefit assessment:

• Do not restart anticoagulation until hemodynamic stability is confirmed, hemoglobin is stable for 48-72 hours, and follow-up imaging shows no hematoma expansion 1, 2, 4
• For patients with high thrombotic risk (e.g., mechanical heart valves, recent DVT/PE), consider inferior vena cava filter placement as a bridge rather than immediate anticoagulation restart, given the heightened rebleeding risk 2
• INR should be normalized (typically <1.5) before any consideration of restarting anticoagulation 4
• When restarting is necessary, use the lowest effective dose and ensure close monitoring with repeat imaging within 1 week 2, 4

Monitoring Protocol

• Hemoglobin/hematocrit checks should be performed at 6-12 hours, 24 hours, and 48 hours post-discharge to detect occult bleeding 1, 4
• Vital signs monitoring: patients or caregivers should monitor for tachycardia (HR >100) or hypotension (SBP <100 mmHg) 1
• Follow-up imaging (CT or ultrasound) should be obtained within 4-7 days to confirm hematoma stability or resolution 3, 4
• Clinical follow-up appointment within 24-48 hours with a surgeon or primary care physician is mandatory 4

Critical Pitfalls to Avoid

• Do not discharge patients with ongoing hemodynamic instability, dropping hemoglobin, or signs of active bleeding—these require admission and possible intervention 1, 4
• Do not overlook abdominal compartment syndrome, which presents with bladder pressures >20-25 mmHg, respiratory distress, and oliguria—this requires emergent surgical decompression 1
• Do not restart anticoagulation prematurely without documented hematoma stability, as rebleeding carries significant mortality risk (6.45% overall mortality in conservative management) 4
• Do not assume all patients are suitable for outpatient management—elderly patients with comorbidities, large hematomas (>10 cm), or Type 3 hematomas (extending below arcuate line) often require inpatient observation 1, 5, 4

Specific Discharge Instructions

• Provide written instructions detailing all red-flag symptoms in clear, simple language 6
• Ensure 24-hour emergency contact availability or clear instructions to return to the ED 6
• Arrange telephone follow-up within 24 hours to assess symptom progression 6
• Prescribe hemostatic agents (tranexamic acid 1g TID and carbazochrome) for outpatient use if bleeding risk remains but patient is otherwise stable 3
• Educate on fall prevention, as orthostatic hypotension from blood loss increases fall risk 1