Retroperitoneal Organs

• Adrenals
• Aorta 
• IVC
• Duodenum
• Pancreas
• Ureters
• Colon (Ascending and Descending) k
• Kidneys
• Esophagus
• Rectum

Physical Exam Findings

• Won't show up acutely
• Grey  Turner's
• Cullen's
• Stabler's sign
• Fox's sign
  

Symptoms

     1. Most common presenting complaint = abdominal pain; then leg/hip pain; back pain

     2. Can have femoral neuropathy, iliopsoas spasm


Traumatic RPH

• Majority are blunt injuries 
  

Spontaneous RPH

• Elderly, anticoagulated pts - significant mortality
• 33% of people with spontaneous RPH are not anticoagulation 
• Consider in people with vague hip / leg pain

Management
- controversial

      Zone I - concern for vascular injury - likely OR

      Zone II & III - ?pulsatile, ?expanding - determines intervention

      Packing vs arterial embolization - majority of traumatic RPH are venous in nature


CORE CONCEPTS:

-  RPH is a rare diagnosis with significant mortality - see keep on your differential!
- Undress your adult patients too - look for Fox's sign, etc
- Most common presenting symptom: abdominal pain, then leg or back pain 
- Seen more commonly in elderly and those on anticoagulation, but 1/3 of pts who presented with spontaneous RPH were not on anticoagulation

Hemophilia A/B
- Hemophilia A much more common than hemophilia B
- present with delayed bleeding
- severity: severe( spontaneous bleeding), moderate( occasional bleeding), mild
- inheritance: X linked recessive, 30% spontaneous

- Dx- often done early in life, can get PT, PTT, BT, platelet count if no Dx and bleeding

Hemathroses:
- ankles, elbow, knee
- 15-40x risk septic arthritis, arthrocentesis only if concern for septic joint or no improvement in 24 hr- Treat with major dose factor if obvious effusion (if not, just routine dose), RICE, crutches, follow up with hematology

Muscle bleeds: 
- Dx with US, CT, MRI
- Watch out for compartment syndrome (especially iliopsoas) or airway compromise 

CNS hemorrhage:
- Give factor prior to getting CT. 

Therapies:
- Factor 8 major dose: 50 U/kg, Routine dose 25 U/kg
- Factor 9 major dose: 80-100 U/kg, Routine dose 50 U/kg

     - talk to family and patient, use their factor if available, needs it's own IV, avoid IM injections
     - Factor must be reconstituted, 30 minute turnaround call pharmacy ahead of time

- DDAVP release Von willebrand ( 0.3 mcg/kg)

- cryo, antifibrinolytics, fibrin glue