What is the management for an increasing size hematoma?

From the Guidelines

Immediate medical attention is necessary for an increasing size hematoma, with a focus on controlling the underlying cause of bleeding and preventing further expansion, particularly in critical locations such as intracranial or retroperitoneal areas. Management of an increasing size hematoma depends on its location, size, and the patient's clinical status. For small, stable hematomas, conservative management is appropriate, including rest, ice application for 15-20 minutes every 2-3 hours, compression with an elastic bandage, and elevation of the affected area above heart level (the RICE protocol) 1. However, for rapidly expanding hematomas, immediate intervention is crucial to prevent further complications.

Key Considerations

• Hematoma expansion is a significant predictor of poor outcomes, including death and disability, particularly in intracranial hemorrhage (ICH) 1.
• Controlling blood pressure is essential, with a target systolic blood pressure of 130-150 mmHg, as elevated blood pressure levels are associated with greater hematoma expansion 1.
• Reversal of antithrombotic agents is critical in patients on anticoagulants, with specific antidotes recommended for different types of anticoagulants, such as four-factor prothrombin complex concentrate for vitamin K antagonists (VKAs) and specific antidotes for direct oral anticoagulants (DOACs) 1.
• Surgical evacuation may be required for large hematomas causing compression symptoms, neurovascular compromise, or those not resolving with conservative measures.

Management Strategies

• Conservative management for small, stable hematomas, including the RICE protocol and analgesics such as acetaminophen or NSAIDs (with caution in active bleeding) 1.
• Immediate medical attention for rapidly expanding hematomas, including blood pressure control and reversal of antithrombotic agents 1.
• Surgical evacuation for large hematomas causing significant symptoms or complications.
• Regular monitoring of vital signs and hematoma size, with attention to signs of infection or compression of vital structures.

Given the high mortality associated with intracranial hemorrhage and the importance of early intervention, immediate medical attention is crucial for an increasing size hematoma, with a focus on controlling the underlying cause of bleeding and preventing further expansion 1.

From the Research

Management of Increasing Size Hematoma

• The management of an increasing size hematoma depends on the location and cause of the hematoma, as well as the patient's overall health status.
• For intracerebral hemorrhage (ICH), the initial management should focus on urgent stabilization of cardiorespiratory variables and treatment of intracranial complications 2.
• Acute arterial blood pressure reduction is safe and associated with slowed hematoma growth and reduced risk of early neurological deterioration in patients with ICH 2.
• For patients with ICH, management in a specialist neurointensive care unit, where treatment is directed toward monitoring and managing cardiorespiratory variables and intracranial pressure, is associated with improved outcomes 2.
• Medical management of subdural hematomas (SDH) focuses on management of intracranial hypertension, maintenance of adequate cerebral perfusion, seizure prevention and treatment, and maintenance of normothermia, eucarbia, euglycemia, and euvolemia 3.
• There is no evidence to guide the specific management of antiplatelet therapy-related ICH, but treatment options for warfarin reversal include vitamin K, fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa 2.
• Tranexamic acid (TXA) is an antifibrinolytic agent that may be useful in reducing hemorrhage, but its use in patients with increasing size hematoma is not well established 4, 5.

Treatment Options

• Surgical intervention may be necessary for large posterior fossa hematomas or for patients with hydrocephalus 2.
• Minimally invasive surgery may be an option for some patients with ICH 6.
• Medical therapies targeting hematoma expansion, hemoglobin toxicity, inflammation, edema, and anticoagulant reversal may be used to manage ICH 6.
• Anti-seizure medications may be administered to patients with SDH or ICH 3.