If patient develops spontaneous retroperitoneal bleed from coumadin ( no injury or fall or anything) assuming Hgb and vitals are stable and remain stable for a few days. Any point in getting a repeat CT to monitor???
Spontaneous retroperitoneal hemorrhage
- Thread starter Cadet133
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I would follow cinically with vital signs. If clinical symptoms change or you have evidence of mass effect, you eval eval with a non-invasive ultrasound...if for some reason, you think there is new bleed, then CT would be OK.
I would. In the era of doctors that do a billion unnecessary tests, I don't think many would blame you for doing an extra CT sometime in the future for this particular patient.
I can think of a dozen good reasons to do so.
From the most selfish (cover your ass, documenting that this is stable/resolved) to many other reasons. Was the bleed related to a tumor that was not readily seen because of the hematoma? Is it slowly getting larger and potentially causing mass effect? bowel obstruction? ureteral obstruction.
I think the tricky question might be how quickly the first one, and how many times/interval. I am not familiar if any guideline/study exists on the matter, it might be a bit obscure. I would "guess" a short term follow up (days to week) and then another long term follow up (weeks to months).
Then, what about coumadin. I am assuming the patient was not taking it recreationally? What are your plans for it? A small or a decreasing size might be a reasonable clue to restart/continue it but if you dont repeat you might not have this info.
Let us know what you decide to do at the end. I am curious.
I can think of a dozen good reasons to do so.
From the most selfish (cover your ass, documenting that this is stable/resolved) to many other reasons. Was the bleed related to a tumor that was not readily seen because of the hematoma? Is it slowly getting larger and potentially causing mass effect? bowel obstruction? ureteral obstruction.
I think the tricky question might be how quickly the first one, and how many times/interval. I am not familiar if any guideline/study exists on the matter, it might be a bit obscure. I would "guess" a short term follow up (days to week) and then another long term follow up (weeks to months).
Then, what about coumadin. I am assuming the patient was not taking it recreationally? What are your plans for it? A small or a decreasing size might be a reasonable clue to restart/continue it but if you dont repeat you might not have this info.
Let us know what you decide to do at the end. I am curious.
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I still would like to know what is the patient's perspective should you were to "discover" it is getting bigger or causing problems. Would she want to go to the OR for an ex-lap to try to fix it?
Are we talking about a bedbound patient, demented?
If you wouldn't change your management on the info, obviously getting the test then is useless and potentially confusing.
I wonder, how did you discover it? Abdominal pain. Is there a possibility that the patient will keep complaining of abdominal pain, the same pain and in 1 week she still gets a CT regardless of the plan? If that is a possibility then perhaps a scheduled outpatient CT makes more sense that the patient randomly showing up to an ED 10 days later complaining of the same problems because she got impatient of waiting. This could end up on even more testing.
At 80, I'm even less worried about radiation. Costs are a concern but if the patient has medicare (likely) less so. If you are not going to do anything with the info (aka patient wouldn't want surgery/intervention or her baseline is so poor that it is not an option) then obviously don't do it.
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This sounds a lot like medical advice.
D
deleted547339
I’d probably just trend hgb - if sudden drop of hemodynamic instability I would CTA/angio.
No. Never order a test that won't change your management.
D
deleted547339
I wouldn’t say never.
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Yeah it's utopian to preach stuff like that, until it's your name on the chart.
We get tests all the time for the sake of just surveillance. We don't like it, we don't like to admit it, but we do it all of the time. We should just teach it. Why don't we teach what we do in the real world?
In this case, repeat CT, maybe not, serial CBCs should be fine for surveillance. Very low threshold for repeating the scan if Hgb drops, and call IR.
Maybe its because I have only been an attending for 8 + months and it hasn't come back to bite me yet, but I firmly believe in not ordering a test unless it will change my management. In the case in question (stable patient with normal vitals and stable hgb that is days out from their bleed and does not having any signs/symptoms of an expanding hematoma), there is no reason to expose the patient radiation. I absolutely understand that it is the norm in our healthcare system to do things like this, but I disagree with it.
D
deleted547339
I couldn’t care less about the risk of radiation in a patient with a spontaneous RP hematoma - they aren’t going to live long enough to get cancer.
I guess I’m more of a pragmatist. There are lots of times I do tests that don’t change management. I’m also an ER doc. I just don’t have that sort of fight in me. You’re here because you want an x-ray in your knee? Cool, the nurse will come bring your discharge paperwork when it’s negative. Im not ordering MRIs to appease patients, but I’ll get a plain film or flu/rapid strep if it makes the patient happy and saves me 5 minutes.
Definitely hear ya. For the vast majority of medicine, there is no right answer. Just a bunch of maybe slightly better, maybe slightly worse answers, but who really knows...
Agreed.
I am also early in my career and empathize with your sentiment. My approach so far is when something is "borderline" I give the option to the patient. Listen, you are 80 years old and you got this bleed. There is really no firm recommendations to do one thing or the other. It is not unreasonable to just follow it up by symptoms/labwork but I am not opposed to offer you a CT scan in a few days. And then go to into detail into explaining what kind of things you might find and how you would likely proceed with each.
In a different case, for instance, a younger patient with a mechanical mitral valve that NEEDs anticoagulation. I probably just straight go and tell him, I recommend a CT and probably would end up doing more than just one CT until it is resolved..
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Fear not radiation. You get more radiation from the sun. The physicists and electrical engineers who built the CT scanner would tell you the same. The concern is greater in the younger population who get scanned frequently, the Peds Onc population comes to mind.
Just be careful, there's a lot of sharks in the water. And by sharks, I'm not talking about lawyers. I've never been challenged by a lawyer, have been challenged plenty of times by hospital administrators and other arm-chair physicians.
Anyway, you're not wrong in your thinking. Stay gold ponyboy!
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I don't see what a CT would tell you about an RP bleed with stable hemoglobin and vitals that you wouldn't already know (it's fine).
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You know he’s probably too young to
get that reference....
Perhaps true, here you go:
https://www.sparknotes.com/lit/outsiders/quotes/
The Outsiders (film) - Wikipedia
I can think of a few reasons. If you need to make a decision regarding when to restart (if at all) anticoagulation it might be helpful. What about taking a second look when things "cool down". The radiologist might not have seen/reported anything funky other than the hematoma on the first one but who knows, perhaps once the size of the hematoma comes down you can identify some underlying tumor or AVM or some other crap. For all you know, the patient had a surgery 20 years ago or an accident or something and there is a sharp thing inside that went undetected. Who knows, the point is that there might be some value in doing a follow up in certain conditions (not all situations are created equal). And I only mention this as a sort of "devil's advocate" look at the other hand kind of thing. The OP made a decent enough point that I wouldn't necessarily push for a CT myself where this be my patient. However, not all situations are created equal.
As a side note, I see a lot of people preaching 100% evidence-based/guidelines but they practice differently. If you don't believe me, just look at the last 10 months of practice and think of how many times an antibiotic was prescribed for common-cold symptoms, you ruled out ACS on a 40year old marathon runner or any of the sort.
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I don't think I would feel much better about anticoagulation if the active bleed had stopped. It would depend on risks of not anticoagulating vs risk of repeat bleed. Vitals and Hgb suggest no more bleeding.
Point taken about if there is a possible bleeding mass, but I read the OP as checking a scan in a few days. I think you would have to wait longer to identify anything underlying. I was responding to the question that was posed.
Take it up with those people then. I said no such thing.
No. The point I was trying to make is that as a general rule we all "advise" and "teach" the conservative, book, "evidence" medicine but then when it is our patient on the line we tend to be more liberal, even when it is not necessarily the optimal, guideline, evidence-based approach. I have not met a single doctor to date that does not fall for that (and that includes me). I wouldn't believe you are either.
Don't take it in the wrong way, we are humans after all.
You know he’s probably too young to
get that reference....
Hey, I read that book in school haha
