From the Guidelines
Management of subgaleal hemorrhage requires prompt recognition and supportive care, with initial management focusing on hemodynamic stabilization and early haemorrhage control using temporary haemostatic devices and surgery or interventional radiology, as recommended by the most recent guidelines 1. The condition occurs when shearing forces rupture the emissary veins between the scalp and dural sinuses, allowing blood to accumulate in the potential space between the periosteum and galea aponeurotic layer, which can expand significantly due to loose connective tissue attachments. Key aspects of management include:
- Hemodynamic stabilization with close monitoring of vital signs, hemoglobin levels, and neurological status
- Volume resuscitation with isotonic crystalloids (normal saline or Ringer's lactate at 10-20 ml/kg boluses) for signs of hypovolemia, followed by blood transfusions if hemoglobin drops below 8-10 g/dL, with consideration of fibrinogen concentrate or cryoprecipitate and pRBC, or FFP or pathogen-inactivated FFP in a FFP/pRBC ratio of at least 1:2 as needed, as suggested by recent guidelines 1
- Coagulation parameters should be monitored and corrected as needed with fresh frozen plasma (10-15 ml/kg), platelets (10-15 ml/kg), or cryoprecipitate (1 unit per 5-10 kg) if there is evidence of coagulopathy
- Pain management with acetaminophen (10-15 mg/kg every 4-6 hours) is appropriate
- Head elevation at 30 degrees helps reduce intracranial pressure and promotes venous drainage
- Avoid excessive head manipulation and pressure to prevent further bleeding
- Serial head circumference measurements and neurological assessments should be performed regularly to monitor progression Most subgaleal hemorrhages resolve spontaneously within 2-3 weeks with supportive care, but severe cases may require neurosurgical consultation.
From the Research
Management of Subgaleal Hemorrhage
The management of subgaleal hemorrhage can vary depending on the severity of the case. Some key points to consider include:
- Early diagnosis is crucial to improve outcomes and prevent serious complications 2, 3, 4.
- Therapeutic strategy should be based on the severity of each case, with conservative treatment being a valid alternative to surgery in some cases 2.
- Close monitoring of vital signs, hematocrit, blood gases, head circumference, and signs of tissue hypoperfusion is recommended 3.
- In cases of massive subgaleal hemorrhage, complications such as shock and death can occur if left untreated 3, 5.
- Anemia and hyperbilirubinemia can also occur if the hemorrhage is slowly progressive 3.
Risk Factors and Prevention
Some risk factors for subgaleal hemorrhage include:
- Instrumental delivery, particularly with the use of vacuum extractors 3, 6, 4.
- Coagulation disorders, such as hemophilia or neonatal alloimmune thrombocytopenia 6.
- Severe head trauma leading to skull base fractures 2.
- Accidental or abusive hair pulling 2.
- Anticoagulant therapy, such as apixaban 2.
Diagnosis and Treatment
Diagnosis of subgaleal hemorrhage should be considered in any infant with a scalp swelling and a falling hematocrit, and coagulation studies should be performed in all infants with a diagnosis of subgaleal hemorrhage 3. Treatment may involve conservative management, such as close monitoring and supportive care, or more invasive procedures, such as surgery or transfusions, depending on the severity of the case 2, 3, 5.