Unusual Case of Retroperitoneal Bleed

An 61 year old man presented to the ED in obvious shock, pale, unrecordable blood pressure, after collapsing at home. History was initially limited, but he was known to have had a bone marrow biopsy earlier in the day at another hospital.

On examination:

Temperature 35 C

Pale, sweaty, altered conscious state, 

BP - initially unrecordable, HR 106,

On log roll, dressing over bone marrow biopsy site (L side) 

His initial FAST and bloods (pre-biopsy, and post collapse and attendance in ED). 

He was treated with blood products (Packed cells and FFP), targeting a BP around 90mmHg which coincided with recovery to baseline mentation

+ What does the CT scan show.

Active bleeding from a branch of the left internal iliac artery into a large left psoas / retroperitoneal haematoma. There is also a very large ascending aortic aneurysm.

+ Post CT the patient once again became hypotensive. What are the disposition options?

The ideal next step is transfer for angio-embolisation by interventional radiologist.
The patient is unlikely to survive open laparotomy.

+ Outcome

Transferred to interventional radiology suite for embolisation of the L internal iliac vessel.

The angiography demonstrated a pseudoaneurysm arising from the anterior division of the L internal iliac artery. A 5 x 22mm covered advanced V12 stent was placed, which successfully excluded the pseudoaneurysm.