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  • • Nonlocalizing abdominal, flank, or low back discomfort

    • Dropping Hct with or without clinical evidence of hemorrhagic shock

    • Occurs in patients with a history of trauma, femoral vascular access, or anticoagulation/antiplatelet medications

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Epidemiology

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  • • Spontaneous retroperitoneal hemorrhage occurs in critically ill patients who are taking anticoagulant or antiplatelet medications, or both

    • Femoral vascular access common etiology of clinically silent large retroperitoneal hematoma formation

    • Traumatic retroperitoneal hematoma can occur after either blunt or penetrating trauma

    • Traumatic retroperitoneal hematomas divided into 3 anatomic zones:

    • -Zone 1: Centrally located, associated with pancreaticoduodenal injuries or major abdominal vascular injury

      -Zone 2: Flank or perinephric regions, associated with injuries to the genitourinary system or colon

      -Zone 3: Pelvic location, frequently associated with pelvic fractures or ileal-femoral vascular injury

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Symptoms and Signs

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  • • Symptoms depend on anatomic location of the retroperitoneal hemorrhage

    • Nonlocalizing abdominal, flank, or low back discomfort

    • Subtle increasing abdominal girth with more cephalad located hemorrhage

    • Pelvic hematomas may compress the bladder causing urinary symptoms

    • Pancreaticoduodenal hematomas may cause gastric outlet obstruction

    • Perinephric hematomas may manifest in hematuria

    • Femoral nerve palsy

    • Flank and groin ecchymosis are a late sign of retroperitoneal hemorrhage

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Laboratory Findings

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  • • Cardinal laboratory finding is a falling Hct

    • Ancillary laboratory findings are depend on associated organ injury such as elevated amylase/lipase with pancreatic injury

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Imaging Findings

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  • Abdominal/pelvic CT with IV and PO contrast: Demonstrates the retroperitoneal hematoma as well as associated vascular or organ injury

    CT scan: Reliably differentiates between hematoma, tumor, and abscess

    US: Useful as an initial study to verify the presence of a hematoma

    • US bladder scan can diagnose pelvic hematoma in patients with urinary symptoms following femoral vessel catheterization

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  • • Retroperitoneal tumors

    • Retroperitoneal abscess

    • Intraperitoneal process with retroperitoneal extension

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Rule Out

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  • • Associated vascular or adjacent organ injury:

    • -Pancreaticoduodenal injury

      -Abdominal or pelvic vascular injury

      -Renal laceration

      -Ureter disruption

      -Bladder injury

      -Ascending/descending colon injury

      -Pelvic fracture

      -Femoral pseudoaneurysm formation

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  • • Serial Hgb evaluation

    • Coagulation assessment

    • Amylase and lipase

    • UA

    • Trauma work-up as indicated

    • Abdominal/pelvic CT scan with IV and PO contrast

    • Angiogram

    • Obtain IV urogram (sometimes)

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When to Admit

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  • • All patients should be admitted and closely monitored in the acute setting

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When to Refer

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  • • Referral depends on etiology and/or anatomic location of injury:

    • -Trauma

      -Vascular

      -Orthopedic

    • Spontaneous retroperitoneal hemorrhage as well as many blunt pelvic vascular injuries can be successfully managed in interventional radiology with percutaneous embolization techniques

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  • • Large bore IV access

    • Type and cross

    • Normalization of coagulation factors

    • Serial Hct evaluation

    • Patients with spontaneous retroperitoneal hemorrhage as well as blunt zone ...

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