Retroperitoneal Bleed

Patient Presentation:
Patient R.E. is a 53-year-old male who presented to the ED with 8/10 chest pain.  EKG in the emergency department showed ST segment elevation.  Patient was emergently taken to cardiac catheterization lab for a PCI, and had two cardiac stents placed in his RCA and LAD.  Right femoral sheath was removed in the cath lab with manual pressure.  Patient was then transferred to the post cardiac intervention unit for observation on telemetry.  Right groin site checks, frequent vital signs and complete bed rest with HOB flat were ordered per physician.  Patient vital signs on arrival to cardiac unit were HR-normal sinus rhythm at 75, BP-134/84, RR 14, and temperature 36.7.  Cardiac enzymes were elevated related to the myocardial infarction, and his CBC and BMP were within defined limits with hemoglobin of 12, and hematocrit of 32.  Patient denied any chest pain/shortness of breath.  Approximately one hour after patient arrived to the unit, the patient complained of “feeling light headed", with 8/10 severe back pain and right groin pain.  Patient appeared diaphoretic and pale.  On assessment of groin site, groin was firm without thrill.  Abdomen was firm with hypoactive bowel sounds.  Vital signs were BP 75/45, HR 150, RR 22, and Temp 37.7.  Repeat Hemoglobin was 8 with a hematocrit of 22.   

Differential Diagnosis:
Pseudoaneurysm, AV fistula, femoral hematoma, retroperitoneal bleed

Diagnosis:
The symptoms of severe back and groin pain, and the sudden drop in hemoglobin and hematocrit, suggested a retroperitoneal bleed.  Once patient was stabilized, CT scan confirmed retroperitoneal bleed. 

Treatment:
Manual pressure was held on the right groin site for 30 minutes followed by a 5 pound sand bag.  Patient was given 3L fluid bolus of normal saline, 2 units of blood, and placed on 2L nasal cannula for initial management.  Once patient was stable, he was taken for a STAT abdominal CT scan to confirm diagnosis and evaluate extent of bleed.  Patient was evaluated for interventional repair of bleed, and surgical evacuation of hematoma.    

Outcome:
Manual pressure and fluids stabilized patient, and bleeding stopped.  Patient did not require any further intervention. Hemoglobin and hematocrit stabilized to normal limits.  Patient remained hospitalized for 3 days post retroperitoneal bleed without any further complications.