What is the treatment for hematoma in the Emergency Department (ED)?

From the Guidelines

Hematoma treatment in the emergency department should prioritize immediate control of obvious bleeding, with a focus on assessment, stabilization, and appropriate intervention based on the hematoma's location, size, and associated symptoms, as outlined in the most recent European guideline on management of major bleeding and coagulopathy following trauma 1.

Key Principles

• For small, uncomplicated hematomas, the RICE protocol (Rest, Ice, Compression, Elevation) is recommended for the first 24-48 hours.
• Analgesics such as acetaminophen (500-1000mg every 6 hours) are preferred initially, while NSAIDs like ibuprofen (400-600mg every 6-8 hours) should be avoided in the first 24 hours as they may increase bleeding risk.
• Severe or expanding hematomas, especially those in critical locations like the head (epidural, subdural), may require immediate surgical evacuation.
• Patients with coagulopathies or on anticoagulants need special attention, potentially requiring medication reversal with agents like protamine (for heparin), vitamin K or prothrombin complex concentrate (for warfarin), or specific reversal agents for DOACs, as suggested by the European guideline 1.

Management of Bleeding and Coagulopathy

• The initial coagulation resuscitation strategy for patients with expected massive haemorrhage should comprise either: fibrinogen concentrate or cryoprecipitate and pRBC OR FFP or pathogen-inactivated FFP in a FFP:pRBC ratio of at least 1.2 as needed, according to the European guideline 1.
• Tranexamic acid should be administered to the trauma patient who is bleeding or at risk of significant bleeding as soon as possible, en route to the hospital if feasible, over 10 min, followed by an intravenous infusion of 1g infused immediately upon hospital admission, as recommended by the guideline 1.

Monitoring and Education

• Serial neurological examinations are crucial for head hematomas, while compartment syndrome monitoring is essential for extremity hematomas.
• Patients should be educated about warning signs requiring return to the ED, including increasing pain, numbness, weakness, or expanding swelling, as emphasized in the guideline 1.

From the Research

Hematoma Treatment in the ED

• The treatment of hematoma in the ED involves various approaches, including the use of tranexamic acid (TXA) to prevent traumatic exsanguination 2.
• TXA is an antifibrinolytic agent that competitively inhibits plasminogen activation, thereby reducing conversion of plasminogen into plasmin and preventing fibrinolysis and hemorrhage 2.
• The optimal dose of TXA administration is a loading dose of 1 g, followed by 1 g infusion over 8 hours, given by intravenous administration within a 3-hour window period of traumatic injury 2.

Management of Major Bleeding in the ED

• Major bleeding is a life-threatening condition that requires aggressive resuscitation and a holistic individualized approach, including haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding 3.
• The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a widely accepted method for immediate assessment and treatment of clinical emergencies, including major bleeding 4.

Use of Tranexamic Acid in Prehospital Setting

• The use of TXA in the prehospital setting has been shown to be effective in reducing mortality among trauma patients with bleeding, with a significant reduction in 24-hour mortality 5.
• Prehospital TXA is considered a primary hemostatic intervention in the treatment of bleeding, alongside blood product transfusion 5.

Massive Hemorrhage Protocol

• A massive hemorrhage protocol is a comprehensive approach to the care of patients with life-threatening traumatic hemorrhage, including damage-control resuscitation and early-ratio-based blood product administration 6.
• The 7 Ts of massive hemorrhage protocol provide a pragmatic framework to guide the care of patients with life-threatening traumatic hemorrhage, including more than blood product administration alone but rather a comprehensive suite of treatments 6.