Married to husband Kevin for 6 years Reside in Lebanon, IN 3 dogs and 2 cats Graduated from IU School of Nursing in 2007 MSN from Indiana State

Transcription

1 Married to husband Kevin for 6 years Reside in Lebanon, IN 3 dogs and 2 cats Graduated from IU School of Nursing in 2007 MSN from Indiana State University 2012 NP at Center for Healthy Aging April 2013-December 2014 NP at Excell for Life Family and Pediatrics December 2014-present

2 There are no relevant personal financial relationships

3

4 The only source of knowledge is experience. Albert Einstein -

5 A localized swelling that is filled with blood caused by a break in the wall of a blood vessel. The breakage may be spontaneous or caused by trauma. Bleeding disorders and anticoagulation therapy can contribute to hematoma formation. Elderly population is at risk due to Increased use of anticoagulation Polypharmacy Immobility/increased risk for falls Neuropathy Vascular disease

6 Tender/painful Warm Erythema or ecchymosis Localized swelling/ palpable mass Positive Homan s sign

7 Hematoma Deep Vein Thrombosis Ruptured popliteal cyst Infection Sarcoma Lymphedema Coup de fouet syndrome

8 CBC PT/INR, other coagulation studies Ultrasound/venous doppler Venography Computed tomography (CT) Magnetic resonance imaging (MRI)

9 Stop anti-coagulants Blood products Pain control- avoid NSAIDS Surgical Excision Monitor closely may reabsorb spontaneously If suspicion for concurrent infection- antibiotics

10 Compartment syndrome Tissue Necrosis Infection Loss of limb

11 Case Study #1 75-year-old white male Medical History Hypertension Chronic atrial fibrillation Peripheral vascular disease Medications: Aspirin Digoxin Prazosin HCTZ Lisinopril Potassium Salsalate

12 PE: Mild erythema on posterior aspect of calf Warmth Swelling Diffuse tenderness Ecchymosis distally at level of the malleoli Positive Homan s sign Laboratory data: WBC 8.2 ESR 35mm/hr Coagulation parameters normal

13 Treatment: Started on a course of oral erythromycin for presumed cellulitis. No improvement in symptoms after 3 days, worsening pain and swelling. Ultrasound did not reveal DVT or a mass. Pt. admitted to the hospital and given IV ampicillin. 5 days later a repeat ultrasound demonstrated a posteromedial calf mass. MRI showed a hematoma deep with in the gastrocnemius. Patient was referred for surgical evaluation and 300ml hematoma was evacuated. The patient was discharged on POD #2 and fully recovered by 8 months post op.

14 Case Study #2 63-year-old male Medical History: History of hepatitis Atrial septal defect repair Mitral valve replacement Acute arterial embolic episodes of the extremity Medications: Warfarin Aspirin (other meds unknown) PE: Local tenderness Slight swelling of inner-anterior aspect of right thigh

15 Ultrasound revealed a hematoma within the vastus medialis muscle Warfarin was stopped for 3 days and the symptoms subsided after conservative management for 2 weeks. 5 years later patient was readmitted to the hospital with severe pain in the right lower leg. Pt continues on warfarin and aspirin. PE: peripheral arterial pulses easily palpable Leg swelling INR 3.59 CT scan revealed a very large hematoma in the right soleus and gastrocnemius muscles.

16 Anticoagulation therapy was held for 7 days. 50mls of dark bloody fluid was obtained by needle puncture. Patient s symptoms completely resolved at time of discharge.

17 Case Study #3 81-year-old female Medical history: Congestive heart failure Atrial fibrillation Right total knee replacement Medications: Warfarin Aspirin

18 Patient diagnosed with spontaneous expanding right medial lower leg hematoma and referred to wound services on day 4. Due to the rapid expansion of the hematoma patient was referred for surgical treatment. Patient required surgical excision down to the muscle fascia with hematoma evacuation.

19 Case Study #4 93-year-old white female Medical hx: Recently discharged from hospital after treatment for cardiac arrest Diabetes Hx of DVT Hx Bilateral PE Dementia Medications: Warfarin- new start with last 30 days Lexapro Donepezil Levemir Levothyroxine Namenda Oxycodone Zinc Polyethlene glycol PE: Left lower extremity pitting edema Tender echymotic mass Erythema Increased warmth

20 Lab data: Elevated blood glucose INR 2.1 Venous doppler negative for DVT Started on oral keflex for presumed cellulitis No improvement in symptoms 24 hours after antibiotics started 48 hours later nurse concerned that leg was getting worse- more edema, skin darkening Admitted to the hospital, CT scan indicated large soft tissue hematoma. Repeat venous doppler negative. Hgb 7, WBC 13. 2units PRBC. IV antibiotics were continued throughout her hospital stay. I and D, surgical debridement and skin grafts later discharged to ECF.

21 Case Study #5 85-year-old female Medical History: Recent CVA with left sided hemiparesis Atrial fibrillation HTN HLD Medications: Warfarin new start within last 30 days aspirin Flexeril Hydrocodone/apap Vitamin D3 Cyclobenzaprine Ferrous fumarate Lisinopril Metoprolol Vitamin C Digoxin.

22 Pt c/o severe pain radiating from left hip down her leg not relieved with hydrocodone. ROM at hip limited by pain Leg tender to palpation No erythema No edema No increased warmth Lab data: CT scan showed large hematoma poster to hip and along hamstring. INR slightly elevated Hgb 10 Coumadin was held 3 days later SBP dropped to 70 and pt developed dizziness. BP meds were held and po fluids encouraged, when symptoms persisted she was sent to ER. Hgb 9.7 INR 1.28 Mildly elevated bilirubin Given IV fluids and BP meds doses cut in 1/2. Coumadin held until hematoma resolved.

23 Started on warfarin within 30 days of hematoma Supra-therapeutic INR at onset of symptoms Comorbidities Drug interaction with warfarin increase risk of bleeding Case #4 Case #5 Case 1,2,3 unknown Case #2 Case #5 CVD: MI, CVA, HTN, PVD, Afib, valve disease Diabetes: case #4 Dementia: case #4 Depression: case #4 Aspirin: #1*, #2, #3, #5 SSRI: #4 *Case 1 not on warfarin, asa only.

24 Choi, J., Kwon, J. H., Choi, B. K., Shin, S. J., Kim, K. S. & Lee, J. K. (2009). Enoxapain-induced spontaneous thigh bleeding in a hemodialysis patient. The Korean Journal of Nephrology, 28, Hoffman, R. D. & Buckwalter, J. A. (n.d.) Spontaneous calf hematoma: A refort of two cases diagnosed with MRI. The Iowa Orthopaedic Journal,18, Hylek, E. M., Evans-Molina, C., Shea, C., Henault, L. E. & Regan, S. (2007). Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation, 115, doi: /circulationaha

25 Pagan, M. & Hunter, J. (2011). Lower leg hematomas: Potential for complications in older people. Wound Practice and Research, 19(1), Sakakibara, Y., Shizu, A., Yoshiharu, E., Motoo, O., Hiramatsu, Y., Shigeta, O.,... Mitsui, T. (1999). Lower extremity hematoma as a complication of warfarinization in patients with artificial heart valves. Jpn Heart J, 40,