History

• 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

Exam

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

Ddx

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

Workup

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

Results

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

Management

• 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