Hemodynamic Instability in Emergency Department: Giant Rectus Sheath Hematoma and Point-of-Care Ultrasonography

Iatrogenic rectus sheath hematoma (RSH) developed after paracentesis is a rare but life-threatening complication. Mortality rates of patients may increase due to delays in treatment and comorbid conditions. In this article, we present the case of a patient who was unstable in the emergency department and was diagnosed with RSH using point-of-care ultrasonography (POCUS). The importance of POCUS has increased as hematoma manifestations of patients with severe ascites tend to be obscured. POCUS has varied uses in the emergency department, and in this article we emphasize the use of POCUS in a life-threatening case of RSH.


Introduction
Rectus sheath hematoma (RSH) occurs as a result of accumulation of blood in the rectus sheath due to rupture of the epigastric vessels or tear in the muscle fibers. RSH is a rare presentation in the emergency department (ED). In particular, iatrogenic RSH secondary to paracentesis has been reported in less than 1% of the cases [1,2]. Clinically significant and life-threatening hemorrhagic complications are observed much more rarely [1]. Although RSH is a self-limiting condition and spontaneous recovery is often observed, mortality is reported in patients with severe coagulopathy [3].
The use of point-of-care ultrasound (POCUS) in the ED is increasing every day. RSH can be diagnosed promptly with POCUS [4]. Thus, the use of POCUS as a rapid, noninvasive, and inexpensive method of differential diagnosis of critical patients will continue to increase. In this case report, the diagnosis of iatrogenic RSH was made by POCUS in the ED and treatment was initiated.

Case Presentation
A 65-year-old female patient was brought to the ED with a complaint of abdominal pain. The patient had a known history of liver cirrhosis and had undergone paracentesis three days ago due to widespread ascites. She had essential thrombocytosis, rheumatoid arthritis, and hypertension. Vital signs included blood pressure of 75/45 mmHg, heart rate 155/minutes, oxygen saturation 95%, and body temperature 36.3°C. There was tenderness in the abdomen and bulging flanks with fluid wave. There was no ecchymosis, warmth, or discharge at the site of paracentesis. The rest of the examination revealed no distinctive findings except for tachycardia.
Because the patient was intervened three days ago, septic shock due to peritonitis was suspected. POCUS was performed for differential diagnosis, and a hyperdense area with anechoic areas within a diameter of about 11 cm above the intervention site in the abdomen was suspected as hematoma. Power Doppler examination revealed no signs of active bleeding and no pseudoaneurysm ( Figure 1, Video 1). Vital parameters of the patient were unstable, and transfusion was initiated due to a concern of stage 4 hemorrhagic shock. The patient was emergently intubated following deterioration in her level of consciousness. Upon erythrocyte suspension transfusion, the patient's tachycardia improved and blood pressure was 90/60 mmHg. RSH with diffuse ascites and 11 × 11 cm active extravasation and contrast transition was observed on abdominal computed tomography, which was performed for determining the area of hemorrhage ( Figure  2). Patient had active bleeding from the inferior epigastric artery; therefore, percutaneous intervention was not considered by Interventional Radiology.

CT, computed tomography
The patient was admitted to the intensive care and replacement therapy was continued. However, the patient expired due to cardiac arrest which occurred 48 hours after admission.

Discussion
Although RSH is a rare presentation in the ED, it should be considered in critically ill patients. It particularly occurs in patients who sustain abdominal trauma and undergo interventional operations, as well as those who are on anticoagulants [5]. RSH is often spontaneously reabsorbed and is a self-limiting condition; however, very rarely, it can lead to life-threatening hemorrhages. Long-term follow-up of patients with coagulopathy, especially patients undergoing paracentesis for liver cirrhosis, and emergency hospital admission reduces mortality and morbidity.
In previous case reports related to RSH, the area of hematoma was evident on physical examination; however, the distinction was not clear in our case because of the prominent abdominal distension [4]. With the use of POCUS, we were able to confirm the diagnosis of RSH and rule out the presence of abscess collection or peritonitis. Resuscitation of several critical patients is performed appropriately by following the POCUS protocols, but its out-of-protocol use still needs to be carefully evaluated. Echocardiography, pulmonary evaluation, abdominal evaluation, and aortic evaluation are performed according to the protocols. Furthermore, POCUS should be performed to explain the patient's hypotension, as was the case presented here.
RSH should be considered as an important differential diagnosis in patients with abdominal pain presenting to the ED, and a history of coagulopathy should be questioned for hemorrhagic complications. In the case presented in this report, although the patient had mild coagulopathy, it was believed that the hemorrhagic tendency was due to thrombocytosis. Although thrombotic risk is greater than hemorrhagic risk in patients with thrombocytosis, the incidence of hemorrhagic complications is observed to be around 5% [6]. Bleeding