Management of Large Abdominal Hematoma Based on Hemodynamic Status

Initial Assessment and Stabilization

Hemodynamic status is the pivotal decision point for patients with a ≥14 cm abdominal hematoma; stable patients (systolic BP ≥ 90 mmHg, responsive to resuscitation) are managed non‑operatively, whereas unstable patients (persistent hypotension despite resuscitation) require immediate intervention (angioembolization or surgery) [1][3]4.
Maintaining a mean arterial pressure of at least 80 mmHg is recommended to ensure adequate organ perfusion during resuscitation 1.

Non‑operative management is the preferred strategy for stable patients with large abdominal hematomas 1.
Patients should be admitted to an intensive‑care unit with continuous monitoring for a minimum of the first 24 hours 1.
The treating facility must have 24/7 capability for emergency laparotomy, interventional radiology, and endoscopy [1][3].
Clinical and laboratory observation should continue for at least 3–5 days, as the majority of complications occur within this period 1.
Ongoing bleeding is monitored by serial hemoglobin measurements, vital‑sign checks, and abdominal examinations 1.

Contrast‑enhanced CT angiography is the diagnostic modality of choice for stable patients with large abdominal hematomas 2.
Repeat imaging is indicated if the patient’s clinical condition deteriorates or if complications are suspected 1.
Presence of active contrast extravasation on CT mandates intervention even when the patient is otherwise hemodynamically stable 4.

Hemodynamic deterioration (e.g., new or worsening hypotension) 3.
Repeat imaging that shows an expanding hematoma or active contrast extravasation 3.
Development of abdominal compartment syndrome, assessed by intra‑abdominal pressure monitoring [1][3].

Angioembolization is the first‑line treatment for hemodynamically stable patients with documented active bleeding; success rates approach 100 % in appropriately selected patients, including those with transient hypotension responsive to resuscitation 1.
Therapeutic angioembolization can replace surgical intervention in stable patients when the service is immediately available 1.

Immediate surgical exploration is mandatory for:
- Hemodynamically unstable patients who do not respond or only transiently respond to resuscitation 4.
- Patients presenting with peritonitis or signs of bowel perforation 3.
- Failure of angioembolization with persistent bleeding 1.
- Abdominal compartment syndrome requiring decompressive laparotomy 1.

Large retroperitoneal hematomas greater than 4 cm that demonstrate vascular contrast extravasation require immediate intervention, regardless of hemodynamic stability 4.
Management options include angioembolization or surgical exploration, selected according to institutional expertise and resource availability 4.