CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/access-bleeding-hematomaIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • PatientA swelling or a wet drape at the access site, pain, and in the forearm tense skin or pain on passive finger extension 1.
  • MonitorTachycardia and a falling pressure with a large bleed; a vasovagal slowing during compression.
  • LabA falling hemoglobin; an ACT that is still high 1.
  • PatientRadial hematoma grades: I local under 5 cm, II under 10 cm, III forearm below the elbow, IV above the elbow, V ischemic threat 1.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Femoral: firm manual pressure just above the skin entry, over the arterial puncture 1.
  2. Radial: reposition the band slightly proximal to the puncture, or add a second band, and elevate the arm 1.
  3. Call the operator and check the pressure, the heart rate and the ACT.
  4. Stop or hold anticoagulant and antiplatelet infusions if the bleeding is not controlled 1.
  5. Forearm grade II or more: elastic wrap and ice; a blood pressure cuff inflated 20 mmHg below systolic, deflated every 15 minutes 1.
  6. Analgesia; hold pressure long enough: about 2 to 3 minutes per French size of the femoral sheath 2.
  7. Ultrasound the groin once controlled to exclude a pseudoaneurysm or a fistula 1.
  8. Grade V radial hematoma or compartment syndrome: emergency fasciotomy 1.
  9. Uncontrolled femoral bleeding: endovascular or surgical repair, as for retroperitoneal bleeding 1.

Equipment

From the complications cart. Linked items open in the equipment directory.

  • Radial compression bandsDirectory: TR Band, PreludeSYNC radial compression device.
  • Femoral compression deviceDirectory: FemoStop Gold.
  • Blood pressure cuff for the forearmBelow systolic, deflated every 15 minutes 1.Not in the directory yet.
  • Elastic bandage and iceFor a forearm hematoma 1.Not in the directory yet.
  • Vascular ultrasoundFor the groin after bleeding stops 1.Not in the directory yet.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

Who to call

The escalation ladder, first call first.

  1. Operator: for any hematoma that grows despite pressure.
  2. Second nurse: to hold pressure while the first prepares supplies.
  3. Vascular surgery: for a forearm compartment syndrome or femoral bleeding that pressure does not control 1.
  4. Interventional cardiology or radiology: for endovascular repair of a femoral bleed 1.

The bailout step by step

Holding femoral pressure that works 21

  1. Find the pulse above the skin nick: the arterial puncture sits proximal to the skin entry 1.
  2. Three fingers over and above the puncture, enough pressure to stop the bleeding with a faint distal pulse.
  3. Hold without peeking about 2 to 3 minutes per French of the sheath 2.
  4. Release slowly over a few minutes, watching for oozing.
  5. Compressive dressing and bed rest for 6 to 8 hours 1.
  6. Ultrasound if a pulsatile mass, a bruit or continued swelling 1.

Prevent

  • Radial access where possible 4.
  • Ultrasound and fluoroscopic guided femoral access at the common femoral artery 1.
  • Avoid supratherapeutic anticoagulation; control blood pressure 1.
  • Place the radial band slightly proximal to the skin entry 1.

After care and documentation

  • Mark the hematoma edges and recheck; serial hemoglobin.
  • Grade and document the hematoma and the treatment; record transfusions.
  • Ultrasound before discharge if the groin is still swollen or a bruit is heard 1.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0021: Swelling at the access site
  • EMG-0046: A wet drape and a growing lump in the groin

References

  1. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 29, Vascular access complications.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 11, Access closure.
  3. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  4. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. J Am Coll Cardiol 2022;79:e21-e129.
  5. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/access-bleeding-hematoma. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.