A 74-year-old man with type 2 diabetes is admitted to the cardiac care unit after an episode of substernal chest pain. He has no history of coronary artery disease. He was hospitalized two years ago for lower gastrointestinal bleeding and one year ago for community-acquired pneumonia. He has non-specific ECG changes, and his initial troponin I level is 1.3 ng/mL. Cardiac catheterization is performed showing 95% proximal left anterior descending artery stenosis and 85% proximal right coronary artery stenosis. No intervention is performed and coronary artery bypass surgery is planned for the following day.
Five hours after the catheterization procedure, the patient complains of generalized weakness and back pain. He appears to be diaphoretic and clammy. His blood pressure is 77/55 mm Hg and pulse is 122/min and regular. His neck veins are flat. Heart sounds are normal and the chest is clear to auscultation. The site of arterial puncture at his groin is mildly tender without subcutaneous hematoma. He receives 1 liter of normal saline with symptomatic improvement. Repeat blood pressure is 92/60 mm Hg and pulse is 96/min. His ECG is unchanged from the previous one.
Which of the following is the best next step in managing this patient?

Question

A 74-year-old man with type 2 diabetes is admitted to the cardiac care unit after an episode of substernal chest pain.  He has no history of coronary artery disease.  He was hospitalized two years ago for lower gastrointestinal bleeding and one year ago for community-acquired pneumonia.  He has non-specific ECG changes, and his initial troponin I level is 1.3 ng/mL.  Cardiac catheterization is performed showing 95% proximal left anterior descending artery stenosis and 85% proximal right coronary artery stenosis.  No intervention is performed and coronary artery bypass surgery is planned for the following day.
Five hours after the catheterization procedure, the patient complains of generalized weakness and back pain.  He appears to be diaphoretic and clammy.  His blood pressure is 77/55 mm Hg and pulse is 122/min and regular.  His neck veins are flat.  Heart sounds are normal and the chest is clear to auscultation.  The site of arterial puncture at his groin is mildly tender without subcutaneous hematoma.  He receives 1 liter of normal saline with symptomatic improvement.  Repeat blood pressure is 92/60 mm Hg and pulse is 96/min.  His ECG is unchanged from the previous one.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

This patient's presentation is consistent with retroperitoneal bleeding caused by cardiac catheterization. Arterial puncture above the inguinal ligament may result in bleeding that can extend into the retroperitoneal space. Bleeding does not usually cease with manual compression and can lead to rapid exsanguination. Patients typically present with hypotension and a drop in hemoglobin. Some patients may complain of flank or back pain. Retroperitoneal bleeding can occur many hours after the procedure, even after initial hemostasis has been achieved. The use of aggressive antiplatelet and antithrombotic agents increases the risk of periprocedural bleeding. Diagnosis is usually confirmed with CT scan. Successful management of these patients depends on early detection, aggressive volume resuscitation, and blood transfusion. (Choice B) CT scan of the chest can evaluate for aortic dissection. However, this is an extremely rare complication of cardiac catheterization, and is usually due to injudicious guidewire or catheter manipulation in the aorta. Profound hypotension and absence of chest pain are not common with aortic dissection. (Choice C) Emergent echocardiogram can evaluate for cardiac tamponade due to coronary artery perforation. However, it is generally recognized during the procedure. In addition, this patient's flat neck veins and normal heart sounds makes this consideration less likely. (Choice D) Gastrointestinal bleeding severe enough to cause significant hypotension always presents with either hematemesis or blood per rectum. (Choice E) Acute right ventricular or inferior wall infarction can cause hypotension and jugular venous distention. However, the unchanged ECG, flat neck veins, and lack of sudden onset of chest pain or discomfort make this less likely. Educational objective: Retroperitoneal hemorrhage is the most common cause of unexpected mortality in patients undergoing cardiac catheterization. Bleeding results from an arterial puncture above the inguinal ligament. It often presents with sudden onset hypotension and a drop in hemoglobin, and does not usually cease with manual compression. __________ References: Retroperitoneal hematoma in patients undergoing cardiac catheterization (http://www.ncbi.nlm.nih.gov/pubmed/20796167)

A 74-Year-Old Man with Type 2 Diabetes Is Admitted to the Cardiac