FATAL ABDOMINAL WALL HEMATOMA AFTER ENOXAPARIN IN A PATIENT WITH MULTIPLE RISK FACTORS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Rectus sheath hematoma is an accumulation of blood within the rectus sheath, is not usually fatal and can be similar to intra abdominal pathologies. Multiple risk factors are associated with this type of bleeding of the inferior epigastric artery. CASE PRESENTATION: Case of 82 years old female that went to the ER due to chest pain, 6/10 in severity, pounding, non-radiating associated with elevated blood pressure of 270/150mmHg. The patient was admitted with a diagnosis of acute coronary syndrome for which dual-antiplatelet therapy of clopidogrel and aspirin at loading doses and full anticoagulation with subcutaneous enoxaparin 1 mg/kg were given. After a few hours after admission, the patient developed sudden right side abdominal pain but due to the severity of pain she was unable to provide a precise description of the pain. Physical examination was remarkable for right sided abdominal tenderness and a palpable induration of approximately 15cm by 15cm. Carnett's sign and Fothergill's signs were also positive. An abdominopelvic CT scan with PO contrast described a large right sided anterolateral abdominal and pelvic wall hematoma measuring 21.5cm anterior-posterior, 15cm in transverse and 26cm in the craniocaudal direction. The patient developed hemorrhagic shock despite multiple blood product transfusions, aggressive intravenous fluid resuscitation and IV vasopressor therapy. The hypovolemic shock persisted for which emergent exploratory OR was indicated in which evacuation of the hematoma and ligation of inferior epigastric artery were performed. However, the patient subsequently developed multiple organ failure due to persistent hypotension that ultimately caused her death. DISCUSSION: This case resulted in a rare rectus sheath hematoma fatality most likely propagated by the patient's underlying risk factors such as arterial hypertension, asthma, being female gender, advanced age, and receiving a full dose of anticoagulation along with dual antiplatelet therapy. Due to the lack of interventional radiology services in our facility, this patient had an emergent surgical intervention without the expected results as the patient had a prolonged period of hypotension causing multiorgan damage. CONCLUSIONS: Hemodynamically unstable rectus sheath hematoma in a setting where interventional radiology is unavailable, exploratory surgical intervention for ligation or embolization of bleeding vessels and evacuation of hematoma must be performed as soon as possible to avoid fatalities associated with delayed treatment. Reference #1: Nourbakhsh E, Anvari R, Nugent K. (2011) Abdominal wall hematomas associated with low-molecular-weight-heparins: an important complication in older adults, J Am Geriatr Soc, vol. 59 (pg. 1543-5) https://doi.org/10.1111/j.1532-5415.2011.03529.x Reference #2: Peng, Wang B., Luo B. (2014): Spontaneous Abdominal Wall Hematoma Caused By Abdominal exercise as a complication of warfarin therapy. Chinese Medical Journal, Volume 127 - Issue 9 - p 1796 https://https://doi.org/10.3760/cma.j.issn.0366-6999.20132338 Reference #3: Goldstein J., Sebire D. (2013): Abdominal wall haematoma in the obese: a dangerous phenomenon. Journal of Surgical Case Reports, Volume 2013, Issue 7 https://doi.org/10.1093/jscr/rjt060 DISCLOSURES: No relevant relationships by Greisha Gonzalez Santiago, source=Web Response No relevant relationships by Paola Lopez, source=Web Response No relevant relationships by Hiram Maldonado Rivera, source=Web Response No relevant relationships by Carlos Ramos Encarnacion, source=Web Response No relevant relationships by Joel Rodriguez Ramos, source=Web Response