Volume 63, January 2023, Pages 183.e1-183.e3Author links open overlay panelAbstract

Peripheral nerve blocks for pain management have historically been discussed in anesthesiology literature but, until recently, have not been considered in emergency medicine contexts. Transversus abdominis plane (TAP) blocks, in particular, have recently been explored in the emergency department for pain control in acute appendicitis but are potentially helpful for managing abdominal pain of other etiologies. One such pathology is rectus sheath hematomas, where conservative management is often necessary as curative treatments often pose more significant risks than are necessary. We report the case of a 57-year-old female presenting to the emergency department with severe abdominal pain following vigorous exercise. She was found to have a large rectus sheath hematoma on computed tomography. An ultrasound-guided transversus abdominis plane block was performed in the emergency department, and the patient had complete resolution of her pain.

Section snippetsBackground

While ultrasound-guided nerve blocks were introduced to anesthesiology literature in 1978 [1], their application in emergency medicine settings has evolved over the past two decades [2]. These techniques are now considered a vital part of emergency department (ED) acute pain management [3], and are included in the vast majority of emergency medicine residency programs [4]. The transversus abdominus plane (TAP) block is a fascial plane block used to provide somatic analgesia from T6 to L1.

Case report

A 57-year-old female presented to a community-based teaching ED with a 5-h history of severe abdominal pain associated with a left lower quadrant (LLQ) mass, nausea and vomiting following vigorous exercise and abdominal flexion exercise with weights. She also reported experiencing diarrhea over the past several days and stated that her pain was improved with lying down and at rest. Past medical history included stage IA melanoma of the left abdomen, locally excised approximately one year prior.

Discussion

Rectus sheath hematomas are uncommon, yet can cause significant abdominal pain, accounting for one to 2% of all causes of acute abdominal pain [9,10]. While mortality is rare [11], curative treatments such as surgical intervention through laparotomy can often involve greater risks of bleeding than is necessary [10]. Rectus sheath hematoma treatment therefore typically involves symptomatic and supportive management, such as applying ice, administering analgesia, abdominal binders, as well as

Prior presentations

None.

Funding sources/disclosures

None.

Author contribution statement

RTS and AH managed this patient in the emergency department and performed the TAP block. BWS and PWS drafted the manuscript, and all authors contributed substantially to its writing and revision. RTS takes responsibility for the manuscript as a whole.

CRediT authorship contribution statement

Robert T. Stenberg: Writing – review & editing, Resources, Conceptualization. Bhanu Wahi-Singh: Writing – review & editing, Writing – original draft, Investigation. Pia Wahi-Singh: Writing – review & editing, Writing – original draft, Investigation. Andrew Hill: Writing – review & editing, Conceptualization. Erin L. Simon: Writing – review & editing, Writing – original draft, Supervision, Investigation.

Conflicts of interest

None.

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