SAQ 329 – Trauma – spontaneous abdominal wall haematoma on warfarin

Trauma – spontaneous abdominal wall haematoma on warfarin.

a. CT findings

• Large left abdominal-wall haematoma.
• Contrast blush consistent with active arterial bleeding.
• Swirl sign or low-density area within the haematoma suggesting active bleeding.
• No haemoperitoneum or pneumoperitoneum.

b. Valve thrombosis risk factors

• Mitral valve position carries higher risk than aortic position.
• Mechanical/bare-metal valves carry higher risk than tissue valves.

c. Daily risk

• Daily thrombosis risk is low, likely under 1%.

d. Warfarin reversal

• Give vitamin K 10 mg IV.
• Give prothrombin complex concentrate, for example Prothrombinex 50 units/kg IV.
• Consider FFP, for example two units, depending on local protocol and response.

e. Massive transfusion targets

• pH greater than 7.2.
• Lactate less than 4 mmol/L.
• Ionised calcium greater than 1.1 mmol/L.
• Platelets greater than 50 x 10^9/L.
• INR less than 1.5.
• Fibrinogen greater than 1.0 g/L.
• PT/aPTT less than 1.5 times normal.
• Base excess not worse than -6.

f. Further management

• Titrate analgesia, such as fentanyl 25-50 micrograms IV in aliquots.
• Urgent interventional radiology referral for embolisation.
• HDU or ICU admission for close observation.
• Serial haemoglobin, coagulation, lactate, calcium, and clinical reassessment guided by transfusion targets.