What are the discharge instructions for a patient with an abdominal wall hematoma?

Discharge Instructions for Abdominal Wall Hematoma

Most patients with abdominal wall hematoma can be safely discharged home after conservative management with specific monitoring instructions, provided they are hemodynamically stable, have no signs of active bleeding on imaging, and demonstrate clinical improvement. 1, 2

Pre-Discharge Requirements

Before discharge, ensure the following criteria are met:

• Hemodynamic stability: Systolic blood pressure ≥90 mmHg, heart rate <100 bpm, and stable hemoglobin levels without ongoing transfusion requirements 1, 2
• No active bleeding: Contrast-enhanced CT should show no active extravasation; if extravasation is present, intervention (angioembolization or surgery) is mandatory even if the patient appears stable 1
• Clinical improvement: Decreasing pain, stable or shrinking hematoma size on repeat imaging, and no signs of expanding mass 2, 3
• Observation period completed: Minimum 3-5 days of inpatient monitoring for moderate to severe hematomas, as 95% of hemorrhagic complications occur within 72 hours (maximum risk in first 24 hours) 4, 5

Anticoagulation Management

Warfarin should be restarted at 7 days after hemorrhage in patients with low thrombotic risk 4. For patients with high thrombotic risk (prosthetic metal heart valve in mitral position, atrial fibrillation with prosthetic valve, or <3 months post-thrombotic event), low molecular weight heparin should be considered at 48 hours after hemorrhage 4.

Activity Restrictions

• Strict bed rest for the first 72 hours at home to minimize risk of delayed bleeding or hematoma expansion 4
• Avoid heavy lifting (>10 lbs), straining, vigorous coughing, or Valsalva maneuvers for 2-4 weeks as these activities can precipitate vessel rupture 6
• Gradual return to normal activities only after follow-up imaging confirms hematoma stability or resolution 2

Warning Signs Requiring Immediate Return

Instruct patients to return immediately or call emergency services if they experience:

• New or worsening abdominal pain, especially if severe or associated with abdominal distension 2, 3
• Signs of hemodynamic compromise: Dizziness, lightheadedness, syncope, rapid heart rate, or feeling faint 2
• Visible expansion of abdominal mass or new palpable firmness 3
• Fever >38.5°C, which may indicate infected hematoma 2
• Difficulty breathing or decreased urine output, suggesting abdominal compartment syndrome 5

Follow-Up Imaging and Appointments

• Repeat ultrasound or CT scan in 7-14 days to document hematoma resolution or stability 2, 6
• Clinical follow-up within 1 week with the treating surgeon or primary care physician 2
• Serial hemoglobin checks may be needed in the first week for patients who had significant initial bleeding 2

Pain Management

• Acetaminophen is preferred for pain control 2
• Avoid NSAIDs and aspirin until cleared by physician, as these increase bleeding risk 2
• Opioids may be prescribed for severe pain but use cautiously given constipation risk (straining contraindicated) 3

Special Considerations

Patients on anticoagulation require particularly close monitoring as they represent 90.6% of conservatively managed cases and have higher complication rates 2. The decision to restart anticoagulation must balance thrombotic versus hemorrhagic risk and should be made in consultation with the prescribing physician 4.

Common pitfall: Discharging patients too early (before 72 hours) when they have large hematomas (≥14 cm) or were on anticoagulation, as delayed rupture can occur 4, 5, 2. These patients benefit from the full 3-5 day observation period even if initially stable 4.