Timely selection and angiographic embolizations in emergency cases lead to effective management saving lives.

Haemorrhagic shock remains a leading preventable cause of death among trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. An organizational schema dividing the retroperitoneal space into 3 anatomic zones is prevalent. The central-medial zone (zone 1) is between both psoas muscles and contains the abdominal aorta, inferior vena cava, pancreas, and midline duodenal structures. The perirenal zone (zone 2) begins lateral to the psoas muscles on bilateral sides and contains the kidneys, ureters, and portions of the colon. The pelvic zone (zone 3) comprises the bladder and many vascular structures, including a robust network for presacral veins. Additionally, the retroperitoneum contains vital musculoskeletal structures, including the psoas muscles, vertebra, quadratus lumborum, and iliacus muscles, and houses connections to the diaphragm and bony pelvis. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.

 Retroperitoneal hematoma diagnosis is difficult for the astute clinician, as the presentation is variable and nonspecific. Accurate diagnosis requires a high clinical index of suspicion and an accurate and focused history and physical examination. The clinical features of retroperitoneal hematoma are primarily based on the injured organs. The physical examination should start with airway, breathing, and circulation evaluation following standard advanced trauma life support protocol. In most cases, retroperitoneal hematoma diagnosis relies upon computed tomography imaging, which may also identify the underlying cause. Treatment modalities include observation, interventional radiology coiling and embolization, and surgical management for unstable patients.

Spontaneous retroperitoneal hematoma is relatively rare, with a high degree of morbidity and mortality. Much of the literature on the subject is limited to case series and retrospective cohort studies. Trends in the data surrounding spontaneous retroperitoneal hematoma suggest that this diagnosis is more common in older adults, patients receiving anticoagulation therapy, and those with underlying coagulopathy. 

The retroperitoneum is divided into the following 3 anatomic regions to guide therapy and describe the location of the retroperitoneal hematomas:

• Zone 1: The central retroperitoneum from the diaphragm superiorly to the bifurcation of the aorta inferiorly. This zone contains the inferior vena cava, originals of the major renal visceral vessels, duodenum, and pancreas.
• Zone 2: Includes both lateral perinephric areas of the upper retroperitoneum from the renal vessels medially to the lateral reflection of the posterior parietal peritoneum of the abdomen (from the diaphragm superiorly to the level of aortic bifurcation inferiorly). Organs include adrenal glands, kidneys, renal vessels, ureters, and ascending and descending colon.
• Zone 3: This zone is inferior to the aortic bifurcation and includes the right and left internal and external iliac arteries, veins, distal ureter, and distal sigmoid colon and rectum. 

Retroperitoneal injury can result from blunt or penetrating trauma. Blunt trauma is caused by direct energy transfer while penetrating injury directly violates tissue planes. 

The following management approaches for retroperitoneal injuries can range from observation to immediate surgical exploration, depending on the mechanism, affected zone of injury, and organ injury severity:

• Penetrating Injuries
  • Zone 1: Explore as this is likely a significant vascular injury.
  • Zone 2: Selectively explore the kidney for active hemorrhage or an expanding hematoma. Mobilize the colon to rule out retroperitoneal colon injury and explore the ureters if they are near the wound.
  • Zone 3: Explore as this is likely a major vascular injury.
• Blunt Injuries
  • Zone 1: Explore as this is likely a major vascular injury.
  • Zone 2: Explore to assess fan expanding hematoma or one that has failed alternative methods of hemorrhage control (eg, angioembolization). Do not explore a contained, nonexpanding hematoma.
  • Zone 3: Do not explore and utilize a method for hemorrhage control, such as intraoperative preperitoneal packing or angioembolization.

Rectum sheath hematoma (RSH) is a rare and often misdiagnosed disease. Conservative treatment or endovascular embolization might be effective in selected patients with RSH.

Treatment modalities include observation, interventional radiology coiling and embolization, and surgical management for unstable patients. The interprofessional team is prepared to select appropriate diagnostic tests, manage retroperitoneal bleeding, and foster effective teamwork to improve outcomes.