History of Present Illness:
A 62-year-old female on Coumadin for a-fib and metoprolol for HTN presents to the ED for near syncope and urinary retention. She had a cardiac cath 2 days prior. She hasn’t been able to pee more than a few drops since last night and feels like she has to. She feels weak and nauseous and vomited once but denies any fever, chills, hematuria other complaints.
Vital Signs & Physical Exam:
Vital signs are normal except for BP of 77/49 and HR of 108. Physical exam is notable for suprapubic swelling and tenderness. It is otherwise normal with no visible hematomas.
Initial Diagnostic Testing:
- Foley: minimal urine output
- Labs: pending
- Imaging: see bedside US below
ANSWER: What is the most likely cause of the presentation?
- A) Urinary retention + vasovagal hypotension
- B) Hematoma + hemorrhagic shock
- C) Ruptured viscus + septic shock
- D) Bowel obstruction + dehydration
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ANSWERS:
- A) Urinary retention + vasovagal hypotension – unlikely without bradycardia
- B) Hematoma + hemorrhagic shock – CORRECT – The image shows an empty bladder and a hypoechoic pelvic hematoma just behind the rectus abdominus muscle
- C) Ruptured viscus + septic shock – less likely without fever or chills
- D) Bowel obstruction + dehydration – less likely with a single episode of vomiting
CASE CONCLUSION: INR was 3.8. The CT shows show multiple hematomas but no distended bladder. The small white circle is the Foley. The other white areas are active bleeding. Hb dropped from 12 to 8. Patient went to IR for embolization. This was a complication of the the vascular access for the cardiac cath.
