A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 70% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 80% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. On physical examination, he appears diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The right groin arterial puncture site is mildly tender, without any swelling or bruits. He receives 1000 mL of normal saline with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His repeat ECG is unchanged from the initial ECG at presentation. Which of the following is the most appropriate next step in managing this patient?

Question

A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain.  His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus.  He has a history of a diverticular bleed 2 years ago.  After initial workup, cardiac catheterization is performed and shows 70% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 80% right coronary artery stenosis.  Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day.  Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular.  He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort.  On physical examination, he appears diaphoretic and clammy.  Neck veins are flat.  Heart sounds are normal, and the chest is clear to auscultation.  The right groin arterial puncture site is mildly tender, without any swelling or bruits.  He receives 1000 mL of normal saline with symptomatic improvement.  His blood pressure is 96/60 mm Hg and pulse is 85/min.  His repeat ECG is unchanged from the initial ECG at presentation.  Which of the following is the most appropriate next step in managing this patient?

Quizplus · Accepted Answer

This patient's presentation (recent cardiac catheterization, anticoagulation with heparin, sudden onset of hypotension, tachycardia, flat neck veins, and back pain) is consistent with retroperitoneal hematoma due to bleeding from the arterial access site (with retroperitoneal extension). Local vascular complications at the catheter insertion site - bleeding, hematoma (localized or with retroperitoneal extension), arterial dissection, acute thrombosis, pseudoaneurysm, or arteriovenous fistula formation - are the most common complications of cardiac catheterization. Most hemorrhage or hematoma formation occurs within 12 hours of catheterization. Patients with hematoma present with localized discomfort and/or swelling of the soft tissue. If the arterial puncture site is above the inguinal ligament, the hematoma can extend into the retroperitoneal space, even with minimal visible localized hematoma, and present with sudden hemodynamic instability and ipsilateral flank or back pain. Diagnosis is confirmed with non-contrast CT scan of abdomen and pelvis or abdominal ultrasound. Treatment is usually supportive, with intensive monitoring, bed rest, and intravenous fluids or blood transfusion. Surgical repair of hematomas or retroperitoneal hemorrhage is rarely required. Since local hematoma formation is not uncommon, patients should be advised to avoid strenuous activity or lifting heavy objects for one week post catheterization. Radial artery approach leads to fewer local vascular complications, which has led to an increasing number of cardiac catheterizations being performed via this approach. (Choice B) CT scan of chest with contrast can reliably identify acute thoracic aortic dissection. Aortic dissection is an extremely rare complication of diagnostic cardiac catheterization, and usually occurs in the right coronary sinus due to coronary engagement with non-conventional catheters. This patient's clinical presentation is more consistent with retroperitoneal hematoma. (Choice C) Nasogastric tubes may be used to differentiate between upper and lower sources of gastrointestinal bleeding, to detect ongoing bleeding (red blood in lavage), and to remove particulate matter, or blood clots to facilitate endoscopy. This patient does not have any signs or symptoms suggestive of acute upper gastrointestinal bleeding. (Choice D) A stat transthoracic echocardiogram is helpful in the diagnosis of pericardial effusion and cardiac tamponade. Patients with cardiac tamponade would be expected to have distended jugular veins (and not flat neck veins as noted in this patient). (Choice E) This patient does not have any symptoms or ECG changes suggestive of acute ischemia. Proceeding with emergency coronary artery bypass graft surgery in a patient with retroperitoneal bleeding will worsen his clinical condition. Educational objective: Retroperitoneal hematoma can occur as a local vascular complication of cardiac catheterization, and often presents with sudden hemodynamic instability and ipsilateral flank or back pain. Diagnosis is confirmed with non-contrast CT scan of abdomen and pelvis or abdominal ultrasonography. Treatment is usually supportive with bed rest, intensive monitoring, and intravenous fluids and/or blood transfusion. References: Retroperitoneal hematoma following femoral arterial catheterization: a serious and often fatal complication (http://www.ncbi.nlm.nih.gov/pubmed/8476149) Retroperitoneal hematoma in patients undergoing cardiac catheterization. (http://www.ncbi.nlm.nih.gov/pubmed/20796167)

A 76-Year-Old Man Is Admitted to the Coronary Care Unit