A 71-year-old man comes to the hospital due to 3 hours of persistent retrosternal chest pain and dyspnea. After prompt evaluation, he is diagnosed with acute myocardial infarction and undergoes cardiac catheterization. During cannulation of the right common femoral artery, the arterial wall is penetrated superior to the right inguinal ligament. Percutaneous coronary intervention is then performed, after which firm pressure is applied to achieve hemostasis. Soon after the procedure, the patient becomes cold, clammy, and hypotensive. Physical examination shows a 5cm region of ecchymosis surrounding the femoral puncture site. Internal bleeding is suspected. Which of the following is the most likely location of the blood collection?

Question

A 71-year-old man comes to the hospital due to 3 hours of persistent retrosternal chest pain and dyspnea.  After prompt evaluation, he is diagnosed with acute myocardial infarction and undergoes cardiac catheterization.  During cannulation of the right common femoral artery, the arterial wall is penetrated superior to the right inguinal ligament.  Percutaneous coronary intervention is then performed, after which firm pressure is applied to achieve hemostasis.  Soon after the procedure, the patient becomes cold, clammy, and hypotensive.  Physical examination shows a 5cm region of ecchymosis surrounding the femoral puncture site.  Internal bleeding is suspected.  Which of the following is the most likely location of the blood collection?

Quizplus · Accepted Answer

11ec160b_3555_a846_9249_1b163ff7d091_MD0001_00 Vascular access during cardiac catheterization is typically obtained through either the common femoral artery or radial artery. The common femoral artery is the continuation of the external iliac artery as it crosses the inguinal ligament. Arterial puncture above the inguinal ligament increases the risk of retroperitoneal hemorrhage, as this portion of the vessel lies directly inferior to the peritoneum. Accidental puncture of the posterior wall can cause blood to track along the loose connective tissue surrounding the vessel and accumulate within the interfascial planes of the retroperitoneum. Bleeding in the retroperitoneal space cannot be controlled with external compression and can lead to life-threatening hemorrhage. Affected patients typically develop hemodynamic instability with significant hypotension, a drop in hemoglobin, and ipsilateral flank pain. (Choice A) Bleeding into the pelvic cavity is frequently due to trauma (eg, pelvic fracture) or gynecologic hemorrhage (eg, ruptured ectopic pregnancy). Injury to the common femoral artery is less likely to cause intraperitoneal bleeding as the external iliac artery courses underneath the peritoneum. (Choice C) The right paracolic gutter is a peritoneal recess found between the ascending colon and abdominal wall. Fluid (bile, pus, or blood) typically accumulates there from pathology involving the gastrointestinal organs, particularly the appendix and gall bladder. (Choice D) Subcutaneous tissue hemorrhage from an arterial source typically presents with a large area of ecchymosis and a palpable hematoma. Development of significant hypotension is less likely with subcutaneous bleeding, as the potential space for blood accumulation is smaller than with peritoneal or retroperitoneal bleeding. (Choice E) Hemorrhage into the thigh muscles would present with significant pain and edema in the thigh and possibly lead to compartment syndrome (severe pain, absent distal pulses). Educational objective: The optimal site for obtaining vascular access in the lower extremity during cardiac catheterization is the common femoral artery below the inguinal ligament. Cannulation above the inguinal ligament can significantly increase the risk of retroperitoneal hemorrhage. __________ References: Retroperitoneal hematoma in patients undergoing cardiac catheterization. (http://www.ncbi.nlm.nih.gov/pubmed/20796167)

A 71-Year-Old Man Comes to the Hospital Due to 3