Trauma in the elderly: a bilateral rectus sheath haematoma

  1. Michael McArdle 1 , 2
  1. 1 University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
  2. 2 South Warwickshire University NHS Foundation Trust, Warwick, UK
  1. Correspondence to Dr Michael McArdle; michaelmcardle1991@gmail.com

Publication history

Accepted:17 Nov 2023
First published:07 Dec 2023
Online issue publication:07 Dec 2023

Case reports

Case reports are not necessarily evidence-based in the same way that the other content on BMJ Best Practice is. They should not be relied on to guide clinical practice. Please check the date of publication.

Abstract

Life expectancy has more than doubled in the last century, and a new cohort of elderly and increasingly frail patients is presenting to emergency departments with new clinical challenges. When this patient cohort presents after injury, all aspects of clinical practice have to be recalibrated to provide safe and appropriate care. The prevalence of chronic disease, levels of organ failure, multiple comorbidities, greater use of anticoagulation and incidence of recurrent low- and high-impact trauma may delay and obscure diagnosis and, ultimately, increase mortality.

Older age is a risk factor for rectus sheath haematoma (RSH), which is haemorrhage into the potential space surrounding the rectus abdominis muscle/s. It is a rare presentation following trauma but can provide diagnostic challenges and be fatal. Even more rare is bilateral RSH with only 12 reported in the literature since 1981.

This case report describes bilateral RSH presenting in an elderly woman following a fall and the consequences of seemingly minor trauma in the elderly.

Background

Life expectancy has more than doubled in the last century,1 and a new cohort of elderly and increasingly frail patients is presenting with trauma. With advanced age, physiological changes affect all organ systems, increasing the body’s susceptibility and response to trauma. Trauma in the elderly may be referred to as ‘silver trauma’. This is commonly defined as trauma and injury in older patients of retirement age or >65 years who usually have underlying frailty and multiple comorbidities.2

Older age is a risk factor for rectus sheath haematoma (RSH), which results from the extravasation of blood into the potential space surrounding the rectus abdominis (RA) muscle/s. It is a potentially fatal manifestation of abdominal trauma, and mortality may be as high as 25% in anticoagulated patients.3

RSH is an infrequent cause of acute abdominal pain (<2%).4 Bilateral RSH is even rarer, with only 12 documented cases in the literature since 1981.5–7 The author presents a case of a bilateral RSH in an elderly trauma patient. Diagnostic challenges in this case highlighted the importance of advanced imaging and the need to recalibrate clinical suspicion in this patient group. Furthermore, due to an increased susceptibility to trauma and an increased incidence of falls and prevalence of anticoagulation, RSH may be more prevalent and associated with greater morbidity and mortality in the elderly population.8–10 This article aims to raise awareness of trauma among the elderly and the need to carefully assess the consequences of seemingly minor trauma.

Case presentation

A patient in her early 80s was transferred to the emergency department (ED) by ambulance, following a fall at home. The patient was being assisted to stand from a seated position by a family member; when they both lost their balance, the patient fell backwards onto the floor and the family member landed on the patient’s pelvis. The patient reported hitting the back of her head on a carpeted floor but denied loss of consciousness. The main complaint was pain in her right hip.

Her medical history included hypertension, vaginal prolapse (third degree) and recurrent urinary tract infections. There were family concerns about a cognitive decline with a pending memory clinic referral. Her drug history included acetylsalicylic acid (aspirin) and an ACE inhibitor (ramipril) but no anticoagulation.

The patient had a pelvic X-ray completed at triage, which identified a right superior pubic ramus fracture, and her National Early Warning Score (scoring system using a patient’s physiological parameters to detect deterioration used in the UK, see table 1)11 was 1 (tachycardia).

Table 1

National Early Warning Scoring system 2

Physiological parameter 3 2 1 0 1 2 3
Respiration rate (min) ≤8 9–11 12–20 21–24 ≥25
SpO2 scale 1 (%) ≤91 92–93 94–95 ≥96
SpO2 scale 2 (%) ≤83 84–85 86–87 88–92 >93 on air 93–94 on O2 96–96 on O2 ≥97 on O2
Air or O2 O2 Air
Systolic blood pressure (mm Hg) ≤90 91–100 101–110 111–219 ≥220
Pulse (min) ≤40 41–50 51–90 91–110 111–130 ≥131
Consciousness Alert Confused
Voice
Pain
Unresponsive
Temperature ≤35.0 35.1–36.0 36.1–38.0 38.1–39.0 ≥39.1

Example table created by the author used in the National Early Warning Scoring system with physiological parameters as set by the Royal College of Physicians11 was used in all NHS hospitals. Temperature was measured in degrees Celsius. CVPU—confused, responds to voice, responds to pain and unresponsive. O2 represents supplemental oxygen of any kind. Physiological parameters with deviation from normal are given a score and repeated on a regular basis. Such scores can be used to detect patient deterioration.

On examination, the airway was patent, and the patient was breathing spontaneously. The Glasgow Coma Score was 14 (eyes: 4, verbal: 4 and confused and motor: 6). The pupils were equal and reactive to light, measuring 3 mm, and the patient was neurologically intact. There was a 3×3 cm swelling over the external occipital protuberance with tenderness. The overlying skin was intact. Examination of the respiratory and cardiovascular systems was normal. The heart rate was 95 beats per minute in sinus rhythm, and the blood pressure was 167/85 mm Hg. The abdomen was firm, with generalised tenderness over a poorly defined mass in the umbilical and suprapubic areas, raising the clinical suspicion of acute urinary retention or intra-abdominal haemorrhage as a result of the fall. Bony tenderness was noted over the symphysis pubis. A bladder scan showed only 148 mL of urine in the bladder. The patient was incontinent of urine.

A focused assessment with sonography in trauma (FAST) scan was performed. There was no free intra-abdominal fluid. No clear cause of abdominal pain, and tenderness or distension was identified. The FAST scan identified a small and posterior bladder. A ‘whole-body’ trauma CT scan was performed. No abnormality was seen in the head, neck and thorax. CT images of the abdomen and pelvis are shown in figures 1–7.

Figure 1

CT image identifying the superior aspect of the rectus sheath haematoma.

Figure 2

CT image through the rectus sheath haematoma.

Figure 3

CT image with annotation indicating the rectus sheath haematoma width (18.7 cm).

Figure 4

CT image identifying contrast extravasation and active bleeding in the right inferior epigastric artery territory.

Figure 5

CT image with annotation indicating the rectus sheath haematoma anteroposterior depth (7.02 cm).

Figure 6

CT image through the inferior rectus sheath haematoma.

Figure 7

CT image identifying the right pubic rami fracture and blood in the prevesicle space.

On the CT images, the RSH is initially identified as asymmetry of the anterior abdominal wall (figure 1) and then as a large, dense and ovoid/fusiform mass anteriorly. Figure 4 identifies the cause as a branch of the left inferior epigastric artery (IEA) with contrast blush representing active bleeding. Figure 7 shows the right superior pubic ramus fracture and the inferior extent of the RSH with extension into the prevesicle space, confirming type III RSH (table 2). The posterior lie of the bladder described at the FAST scan was likely secondary to a pulling effect from the vaginal prolapse posteroinferiorly and a pushing force exerted by RSH extension into the prevesicle space anteriorly. Diagnosis of RSH was further obscured by the fact that the haematoma was a poorly defined bilateral and midline mass. The much more common unilateral RSH is focal, does not cross the midline and is contained by the linea alba and linea semilunaris. On review of the CT images, it appears that the bleeding initially started in the left rectus sheath as evidenced by the active bleeding of the left IEA. This haemorrhage then caused diastasis of the linea alba, allowing it to become bilateral, and also extended inferiorly via the IEA fenestrations in the rectus sheath. There was additionally a small volume of intraperitoneal haemorrhage that likely represents further RSH extension; however, the pubic ramus fracture may have contributed.

Table 2

Rectus sheath haematoma (RSH) classification

Type I Small and confined within the rectus muscle; does not cross the midline or dissect fascial planes.
Type II Also confined within the rectus muscle but can dissect along the transversalis fascial plane or cross the midline.
Type III Large, usually below the arcuate line, and often presents with evidence of haemoperitoneum and/or blood within the prevesical space of Retzius (retropubic space).

  • Table describing the RSH classification system.67 68

The patient remained haemodynamically stable. She received analgesia, tranexamic acid and intravenous fluids. There was a drop in the haemoglobin level from 159 g/L on admission to 119 g/L when checked 6 days later on the ward. The platelet count on admission was 878×109/L, and thrombocytosis was suspected to be trauma and inflammatory response related and normalised 8 days later. Aspirin was stopped on admission and restarted on admission day 6 when two full blood counts showed plateau and stabilisation of the haemoglobin level. Low-molecular-weight heparin for venous thromboembolism prophylaxis was started on day 12 when the risk of further bleeding was deemed low. The daily full blood count did not identify any further drop in the haemoglobin level. A urinary tract infection was identified on admission using urine microscopy and culture, and sensitivity was managed with oral antibiotics. The patient remained in the hospital for 2 weeks. Her treatment focused on pain management and the expectant management of complications (such as potential secondary infection of the haematoma) with occupational therapy and significant physiotherapy input. Physiotherapy was limited initially due to pain mainly in the right hip and delirium, but with the escalation of analgesia to oral morphine, the patient made progress. On discharge, she was mobilising with a walking stick independently. Before the fall, she had been independently mobile with no aids. Physiotherapy professionals suggested a period of inpatient rehabilitation, but the patient declined and was keen to be discharged home. The patient’s family supported bridging care until her usual three times per day package of care could be restarted. With occupational therapy and general practitioner follow-up, a plan was made for discharge home. Initially, she struggled with abdominal and right hip pain, especially when mobilising. Three weeks after discharge, she was managing well, was independent with activities of daily living and had stopped her oral morphine, and the confusion discovered on admission, believed to be delirium secondary to urinary tract infection, had resolved.

The patient passed away 7 months later from an unrelated illness.

Global health problem list

  • Elderly patients are a growing cohort in need of chronic healthcare, acute care and trauma services.

  • The elderly patient presents unique clinical challenges, especially in the context of trauma.

  • The incidence of RSH and the severity appear to be increasing among the ageing population, and greater use of anticoagulants has been implicated.

Global health problem analysis

Elderly patients represent a large and growing demand on healthcare services globally. The zeitgeist of modern medicine is the reduction of all-cause mortality and the prolongation of life. At the turn of the 19th century, the average global life expectancy was 29 years.1 This figure has risen to 72.98 in 2022 and is expected to increase to 81.88 in 2102.1 12 By 2040, around one in four of the UK population is projected to be 65 years or older, and they represent the fastest growing age group.13 Modern healthcare is largely responsible, and much research especially into chronic conditions uses mortality end points. Interventions with statistically significant mortality reduction and cost-effectiveness filter into clinical practice. However, there is growing consideration and concern for the quality of life, and the recent review by Marmot et al stated that we should be focusing on ‘adding life to years, rather than just years to life’.14 Healthy life expectancy, the length of time a person can expect to live with good health, is declining, and years spent in poor health are increasing in the UK.14 15 Significant contributors are the low rates of physical activity, reducing muscle mass and obesity prevalence. Nearly half, 47%, of adults in the north west of the UK are physically inactive,14 16 39% of the global population is overweight and obese17 and this figure rose to 72% in the UK elderly population (>65 years).18 This is filtering through as a more comorbid and frail elderly population, with obvious consequences for global health. In 2017, the group aged 75 years and older represented 8.2% of the UK population but 22% of hospital admissions.19 Neoteric sources state that older people (>65 years) have admission rates of 40% and occupy 66% of inpatient beds.20 The trauma audit and research network (TARN) observed a twofold increase in major trauma admissions having age >60 years between 2008 and 2017.21 This group represented 54% of all major trauma patients in the UK.21

Older-age physiological considerations and clinical challenges

With advancing age, the physiology of all body systems is affected. Skin thickness becomes reduced. Bone density is decreased, and cardiac output, lung function and muscle mass are degraded.22 Changes in elderly physiology necessitate the tailoring of clinical care. Elderly trauma guidelines use different physiological parameters for triage and reduced thresholds for senior review23–25 as a result of TARN recommendations.21 Special considerations must be applied to all aspects of the primary survey as summarised in table 3.

Table 3

Primary survey in elderly trauma—considerations and reasonable adjustments

Airway+C-spine precautions

  • Bag valve mask ventilation impaired by facial fat deposition and edentulous patients (consider intraoral gauze packing).

  • Hard collars may not provide an adequate fit (blocks/packing with tape used to acquire bespoke immobilisation).

  • Neck mobility impaired by cervical arthritis and bespoke immobilisation positions with reduced mouth opening (expect a difficult airway and plan appropriately).

  • Increased the risk of RSI-induced hypotension because of lack of physiological reserve (reduce sedative RSI medications by 20–40%).69
Breathing

  • Reduced respiratory reserve because of spinal kyphosis, weakened respiratory muscles, decreased chest wall compliance and chronic lung diseases.

  • Decreased compensatory mechanisms for rib/sternal fractures with an increased risk of respiratory decompensation.

  • Blunt chest trauma/pulmonary contusion is common (consider early non-invasive mechanical ventilation).

  • Use the STUMBL score in blunt chest trauma to guide aggressive analgesia and admission team based on complication and mortality risk.70
Circulation

  • Diastolic dysfunction, arrhythmia and cardiomyopathy limit augmentation of cardiac output.

  • Elevated baseline blood pressure may mask or delay hypotension diagnosis (use geriatric-specific physiological parameters).

  • Medications impair tachycardic response to hypoperfusion, leading to pseudo-normal vital signs and false reassurance (identify offending agents and apply to clinical context).

  • Increased risk of fluid overload with resuscitation fluids (consider balanced fluid and blood products with close monitoring, especially if heart failure suspected or diagnosed).

  • Anticoagulant use is prevalent and increases the risk of life-threatening haemorrhage (identify agents, send clotting studies, early TXA and anticoagulant reversal if needed).
Disability

  • Assessment of neurological function can be confounded by dementia/delirium/sedative medications (collateral history important).

  • Brain atrophy, dural changes and anticoagulation increase the risk of intracranial haemorrhage (applying NICE CT head criteria, frequent monitoring and accurately documenting neurological examinations to identify subtle and early deterioration).

  • GCS does not correlate with injury severity in older adults, and pre-existing disease may affect neurological findings.

  • Caution with opioid analgesics, especially if opiate naive or neurological concerns.
Exposure

  • Pressure ulcers can form quickly from backboards or cervical collars (early liberation from immobilisation devices).

  • Impairment of thermoregulation and decreased muscle mass (keep covered and apply passive or active rewarming if needed).

  • Thin collagen-deficient skin requires alternative wound closure (eg, mattress sutures, glue, steri-strips, etc).

  • Be aware of skin findings associated with non-accidental injury.

  • Table summarising the important considerations with reasonable adjustments for the primary survey in elderly trauma (the author’s creation).

  • GCS, Glasgow Coma Score; NICE, National Institute for Health and Care Excellence; RSI, rapid sequence induction; STUMBL, STUdy of the Management of BLunt chest wall trauma; TXA, tranexamic acid;

Additional consideration must be paid to the initiating event as the cause of trauma might reveal a significant medical diagnosis (stroke, acute coronary syndrome, hypoglycaemia, etc) that requires an independent line of clinical enquiry and management. When history taking from the patient is challenging, a collateral history is required to ensure a safe and accurate understanding of the clinical context. Clinical history and examination may be unreliable when patients are confused, agitated or acutely unwell. Special consideration for medications and polypharmacy is essential in the medical history (tables 3 and 4). A high index of suspicion for trauma pathology warrants investigation and bespoke selection of investigation/s, and this responsibility falls within the treating clinician’s remit.

Table 4

Medications that increase the risk of falls in the elderly with causative mechanisms

Medications Mechanism of falls risk
Benzodiazepines Confusion, ataxia, weakness, sedation and delirium.71
Antihypertensives Cerebral hypoperfusion secondary to hypotension and increased risk of orthostatic hypotension. Arrhythmias especially bradyarrhythmias with beta-blockers.
Anticholinergics Anticholinergics have also been implicated through central nervous system effects (possible ataxia, cognitive impairment, dizziness and light-headedness), visual side effects (mydriasis impairing the accommodation reflex)72 and constipation and urinary retention.73
Diuretics Hypotension, dehydration, electrolyte derangement and increased ambulation, especially nocturnal micturition.
Glycaemic agents Hypoglycaemia especially with insulin and diuretic effects from glycosuria with some agents.
Psychotropics Confusion, cognitive impairment, hallucinations, sedation, dizziness, light-headedness, visual disturbance, agitation and delirium. Altered gait and balance.
Opiate analgesics Sedation, confusion, delirium, hallucinations, constipation, urinary retention (secondary to constipation) and dizziness. Altered gait and balance.71

Medication use is growing in the elderly population. One large 2017 study identified that 92.2% of people aged greater than 65 years were prescribed at least one medication, and people taking five or more medications was 49.6%.26 It also demonstrated a rapid increase in medication use between 1991–94 and 2008–11.26 One of the most significant and expensive side effects of elderly pharmacodynamics is an increased risk of falls. One study with over 5000 participants demonstrated a 21% increased risk of falls with patients taking five or more medications.27 Ziere et al reported an increasing risk of falls with the number of medications used per day.28 Falls ‘risk drugs’ were identified, and the OR increased 42% for each at ‘risk drug’ in a patient’s regimen.28 Medication burden and its effects on the elderly are increasing. Greater care is needed in prescribing known high-risk drugs (table 4) in high-risk patient groups, especially when a combination of drugs is used or drugs are added to already extensive regimens. Furthermore, certain medications are likely to feature greater side effect profiles in elderly patients as a result of interplay with changing elderly physiology. These medications usually have dose reduction recommendations. Clinicians must have an appreciation for the combined effects of elderly physiology, an adapted and atypical response to trauma (table 4) and the effects of pharmacodynamics and polypharmacy in the elderly trauma patient.

Current data suggest that older adult patients with hip fractures are three to four times more likely to die within 1 year of surgical intervention than the general population.29 The most recent trauma audit and research network report on trauma in older patients identified shortcomings in care. Older patients were found to be under triaged, and there were fewer prealerts, transfers to major trauma centres, activation of trauma calls and senior reviews.30 It was hypothesised that lower-impact mechanisms provided false reassurance and drove under-reporting. Older patients have lower energy transfer mechanisms of injury, and the most common cause of major trauma in this group is a fall from standing. Due to comorbidity and diagnostic delay, there is an increased risk of death.30

The unique clinical considerations and higher mortality rates of elderly trauma patients have prompted adapted care interventions. In 2019, the advanced trauma life support guidelines introduced elderly patients with trauma as a special population that requires bespoke considerations for safe care.31 There are numerous elderly trauma local guidelines in use in EDs globally, with modifications to all aspects of care.23 30 Many guidelines suggest geriatric assessment within 72 hours; geriatric input has a well-established reduction in mortality, complications, delirium and length of stay in critical care.23 32 Such individualistic approaches improve care and ultimately reduce mortality.24 33 34 A large multicentre study32 did identify an increased length of stay following geriatric assessment, but there is evidence to suggest that geriatric review compliance is variable in the UK.30 Geriatric assessment within 72 hours has been reported to be as low as 41–53.7%30 32 nationally. Geriatric review was proportional to increasing age,30 32 but trauma team activation was inversely proportional.34 Creation of a dedicated, interdisciplinary elderly trauma team can increase major trauma activation and improve survival rates in aged cohorts.34 Indeed, one study observed a mortality reduction by activating a major trauma protocol for all injured patients over the age of 70 years, independent of mechanism or triage physiology.35 The variability in geriatric trauma care is substandard and unambiguous in its effects on patients. In the USA, standardised, evidence-based, multidisciplinary team pathways for older-age trauma have significantly reduced 30-day readmission rates and delirium.30 36

Rectus sheath haematoma

Older age is a risk factor for the RSH,3 37–40 which accounts for <2% of acute abdominal pain presentations.4 RSH results from the extravasation of blood into the fascial compartment (rectus sheath) that encloses the rectus abdominus (RA) muscle/s and its neurovascular supply. The rectus sheath is formed by the aponeuroses of the external oblique, internal oblique and transversus abdominis muscles and the transversalis fascia (figures 8 and 9) and is perfused and perforated posteriorly by the superior and inferior epigastric arteries. Disruption, usually in the form of trauma to these vessels, their branches or the RA, directly can result in life-threatening haemorrhage. Due to the fixed position of the IEA as it enters the rectus sheath at the arcuate line, it is usually the origin of clinically significant bleeding.41 Older age, female gender (F:M 2.5:1), atherosclerosis and hypertension are among the risk factors for RSH.3 37 42 In the elderly population, increased comorbidities, greater use of anticoagulants and sarcopenia all increase the risk of developing a fatal haematoma.8 43 44

Figure 8

The author’s anatomical representation of the rectus sheath and surrounding structures. This is a cross-sectional image through the anterior abdominal wall (above arcuate line). EO, external oblique muscle; EPF, extraperitoneal fat; IO, internal oblique muscle; PP, parietal peritoneum; RA, rectus abdominus; SCF, subcutaneous fat; TA, transverse abdominus muscle; TF, transversalis fascia. L. semilunaris, linae semilunaris unfused for clarity.

Figure 9

The author’s representation of a sagittal section through the rectus abdominus (RA) muscle. EOA, external oblique aponeurosis; EPF, extraperitoneal fat; IEA, inferior epigastric artery; IOA, internal oblique aponeurosis; PP, parietal peritoneum; SCF, subcutaneous fat; TAA, transverse abdominus aponeurosis; TF, transversalis fascia.

Sarcopenia is defined as the progressive involuntary loss of muscle mass and strength that occurs naturally with ageing, and up to 50% of muscle mass is lost by the eighth decade of life.45 46 Increased muscle mass is protective against injury, with reduced muscle mass in women reported to account for the increased incidence of RSH in this group.37 47 Sarcopenia is a well-established risk factor for falls and fractures in the elderly.48

Age-related changes in the abdominal wall result in thinning and increased laxity. This occurs through sarcopenia of the muscular components, which is progressive with age,49 but also thinning and fragmentation of elastin result in connective tissue thinning and loss of elastic recoil.50 This age-related degradation may also explain the falling conservative management rates through later haemostasis and thus greater bleeding. There is a self-tamponade effect exerted by the rectus sheath: internal pressure builds with progressive bleeding and stretch of the rectus sheath walls. This accounts for the high rate of conservative management of RSH. If the walls were to become thinner and more lax, as is seen in the ageing process, there would be more compliance (stretch) and thus a slower pressure build and a later tamponade. With extrapolation, this would follow Laplace’s law, which states that the tension (T) on a cylindrical or spherical wall is a product of the pressure (P) and the radius (R) and is inversely proportional to the wall thickness (w),51 as shown below.

As can be appreciated from the equation, with an increase in pressure, the wall thickness would have to increase to maintain wall tension. As rectus sheath wall thickness decreases with age and increased stretch, a greater pressure would be required to maintain a sufficient wall tension. Clinically speaking, a rectus sheath with age-related thinning and laxity would require higher pressures (a greater volume of haemorrhage) to achieve a sufficient wall tension to facilitate self-tamponade. The elderly patient is thus more likely to have greater degrees of blood loss. This mechanism has not been formally studied or discussed in the literature but is worth researching as rates of RSH increase, and management decisions rest on blood loss and the need to stop active bleeding.

Anticoagulation

There were over 20 million oral anticoagulants dispensed in the UK in 2020.52 One study with >130 000 patients reported that those aged over 60 years represented 85% of all anticoagulation prescriptions.53 The ageing population and anticoagulant burden have been implicated in the rising incidence and severity of the RSH.4 8–10 35 37 38 54 Numerous studies have found anticoagulation to be the most common predisposing factor.37 39 40 42 55 This can be appreciated in figure 10, where average age and anticoagulation rates can be seen to be rising.37–40 55 56

Figure 10

The author’s graphical representation of the temporal changes seen in rectus sheath haematoma (RSH) presentation and management from six of the largest RSH case studies. Mx: management. Observation: consisted of analgesia, rest, compression and intravenous fluids. Medical: consisted of observation interventions and additionally including blood transfusion and anticoagulant reversal. Intervention: consisted of embolisation or surgery.

Early recognition of RSH may be associated with increased survival.3 57 RSH mortality is ~4% but can increase to 25% in anticoagulated patients. Two recent studies with 126 and 115 patients reported anticoagulation rates of 69% and 77.4%, respectively, in RSH patients.37 39 In patients with spontaneous RSHs, the rates of anticoagulation have been reported to be as high as 83–85%.9 40 42 Smaller studies such as Donaldson et al’s9 three patient case series reported that all of their RSH patients were anticoagulated. Despite high rates of anticoagulation in RSH patients the management, however, is usually conservative.40 42 Antiplatelet data suggested an incidence of 29.5–37.5% in RSH patients.37 39 40 Our own patient was taking 75 mg of aspirin daily.

Older-age discharge considerations

A department of health audit, published in 2016, identified that 85% of all delayed discharges were seen in those aged 65 years or older and cost the NHS an estimated £820 million per year.58 The demand for hospital beds is increasing, and the number of patients who remain in hospital while clinically ready for discharge is growing. In December 2022, 16 440 patients fit for discharge occupied hospital beds each day, a figure which increased by 30% from December 2021.59 Nearly a quarter were awaiting care-home beds. This is a global phenomenon, and Landeiro et al identified delayed discharges in 16 countries studied with variable associated costs.59 Older patients are at the greatest risk of such delays, and the detrimental effects on long-term functioning, morbidity and mortality are well documented.60–63 In the September 2022 ‘Our Plan for Patients’64, the government pledged £500 million to ‘support discharge from hospital’, and this figure will climb to 1 billion in 2024–25.59 These plans do not discuss reducing readmission rates. In the UK, 15% of those aged 65 years and over are readmitted within 28 days.65 Reducing readmission in this group is difficult. One systematic review of 32 clinical trials identified statistically significant readmission rates in 10 studies.66 Those trials which included some form of post discharge follow-up had the greatest reduction in readmission.66 Multifactorial, multidisciplinary and fiscal interventions will be needed to improve the efficiency, safety and holistic elements required to discharge elderly patients to appropriate temporary and long-term settings.

Conclusion

In conclusion, the elderly cohort is clinically divergent; older adults present with significant injury following lower-impact trauma, and their presentation after trauma is heterogeneous. They have higher mortality rates, and national trauma data suggested widespread evidence of suboptimal care. Due to deranged physiology, higher rates of anticoagulation and diagnostic challenges, RSH can be fatal in this group. Bilateral RSH presents further diagnostic challenges, and physicians must be aware of its atypical presentation, especially in older adult trauma.

Learning points

  • Even minor trauma in older age groups may result in major injury and comorbidity.

  • Presentations with acute abdominal pain such as rectus sheath haematoma require careful clinical evaluation and complex investigation.

  • High-level trauma and geriatric care may improve outcomes of trauma in the elderly.

Ethics statements

Patient consent for publication

Footnotes

  • Contributors The following author was responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms and critical revision for important intellectual content: MM. The following author gave the final approval of the manuscript: MM. Author MM is sole contributor with no external input or assistance. Local permission was granted for the creation and submission of this case.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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