EpistemisSpontaneous hematoma of the psoas and iliacus muscles
Specialty: Hematology.
Why it occurs
- Severe hemophilia A or B (spontaneous deep muscle bleeding in the iliac fossa due to the almost total absence of factor VIII or IX activity)
- Anticoagulant treatment with vitamin K antagonists (acenocoumarol or warfarin) with a supratherapeutic INR range or hemodynamic instability
- Direct oral anticoagulants (factor Xa or thrombin inhibitors such as rivaroxaban, apixaban or dabigatran, in situations of overdose or severe renal dysfunction)
- Acquired hemophilia due to anti-factor VIII autoantibodies (frequently due to systemic autoimmunity or idiopathic in the elderly)
- Overanticoagulation syndrome due to unfractionated or low molecular weight heparin.
Initial workup
Computed tomography (CT) of the abdomen and pelvis without and with intravenous contrast (gold standard for diagnosing, delimiting the size of the psoas hematoma and ruling out active bleeding through contrast extravasation or arterial "blush"); emergency abdominal ultrasound (useful as a quick initial approach at the bedside of the critically ill patient); immediate analytical determination of complete coagulation times (markedly prolonged aPTT in hemophilias or heparins, very high PT/INR in antivitamin K treatments); serial complete blood count to assess the kinetics of hemoglobin and hematocrit level; blood group typing and emergency cross-match testing in the face of the need for massive transfusion of blood products.
red flags
Presence of persistent arterial hypotension, extreme tachycardia, sweaty mucocutaneous pallor and progressive oliguria (data of hypovolemic shock due to massive sequestration of blood in the retroperitoneal space); severe weakness for ipsilateral hip flexion, abolition of the patellar reflex and hypoesthesia or paresthesias in the anterior aspect of the thigh (femoral neuropathy due to direct mechanical compression of the femoral nerve within the fascia of the iliopsoas muscle, requiring urgent decompression if it progresses); Acute abdominal pain radiating to the iliac fossa that simulates acute appendicitis or diverticulitis with signs of diffuse peritoneal irritation.
Standard management
- Prothrombin Complex Concentrate / CCP — rapid intravenous infusion that provides factors II, VII, IX and X; drug of choice to immediately reverse dicoumarin anticoagulation in the presence of severe bleeding
- Coagulation Factor VIII or IX concentrate — emergency administration in known hemophiliac patients; dose calculated to achieve 80-100% of the normal functional activity of the absent factor
- Idarucizumab — cleaved monoclonal antibody that acts as a specific reversal agent for the direct thrombin inhibitor Dabigatran
- Andexanet alfa — modified recombinant protein that acts as a specific antidote to reverse the anticoagulant activity of factor Xa inhibitors such as apixaban and rivaroxaban
- Tranexamic acid (complementary intravenous antifibrinolytic to stabilize local secondary hemostasis, assessing risk-benefit).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Hematology
- Listed causes
- 5
- Treatment options
- 5