Critical Cases - Active Gluteal Muscle Internal Hemorrhage!


  • 68 yo male hx of atrial fibrillation on apixaban presents after his car was struck on driver's side
  • He denies head injury or loss of consciousness
  • He complains of pain in his left hip/buttock
  • He denies other pain complaints


T 98.8 HR 92 BP 130/80 Pox 98% on RA

  • HEENT: no trauma to the head or face
  • Neck: no midline TTP, C-collar in place
  • Chest: Lungs clear, heart sounds normal
  • Abd: Soft, nontender, no seat belt sign
  • Extrem: L buttock +firm, tender hematoma ~ 5X5 cm


  • Intracranial hemorrhage: Age and anticoagulation increase risk
  • Cervical spine injury: Possible given age and mechanism
  • Thoracic/Abdominal injury: Possible given anticoagulation
  • Hematoma: Intramuscular hematoma


  • Given age, mechanism, and anticoagulation, pt sent for whole body CT (WBCT)


  • CT abdomen/pelvis shows gluteal muscle hematoma with active extravasation





  • Interventional radiology consulted for emergent angiography
  • Pt administered intravenous andexanet alfa for reversal of apixiban
  • Angiography demonstrates active extravasation from a branch of the inferior gluteal artery, which is successfully embolized with microcoils


Take Home Points

  • Consider active arterial hemorrhage in a large or expanding traumatic hematoma
  • This risk is increased in the elderly and pts on anticoagulation
  • Andexanet alfa is a drug approved for use to reverse apixaban and rivaroxaban in cases of serious hemorrhage, typically reserved for pts undergoing operative intervention due to cost
  • Angiography is the preferred method for control of deep muscle hematomas with active extravasation