Initial Management of a Hematoma
The initial management for a patient presenting with a hematoma should focus on controlling obvious bleeding points through direct pressure, tourniquet application, or hemostatic dressings, followed by assessment of the patient's hemodynamic status and determination of the hematoma's cause and extent. 1
Assessment and Diagnosis
Initial Evaluation
- Assess hemodynamic stability:
- Heart rate, blood pressure, capillary refill, skin color, level of consciousness
- If patient is conscious with palpable peripheral pulse, blood pressure is likely adequate 1
- Evaluate the hematoma:
- Location, size, and expansion rate
- Look for obvious blood loss (on clothes, floor, drains)
- Look for indications of internal blood loss 1
Diagnostic Workup
- Obtain baseline blood tests:
- Complete blood count
- Coagulation studies (PT, aPTT, fibrinogen)
- Type and cross-match 1
- Imaging based on location and clinical status:
Management Strategy Based on Hematoma Type and Severity
Hemodynamically Unstable Patients
- Control obvious bleeding points immediately 1
- Establish large-bore IV access (peripheral or central) 1
- Begin fluid resuscitation with warmed blood products if massive hemorrhage 1
- Maintain target systolic BP of 80-100 mmHg until major bleeding is controlled (if no brain injury) 1
- For patients with identified bleeding source and ongoing shock, proceed to immediate bleeding control procedure 1
Hemodynamically Stable Patients
- Monitor vital signs closely (every 15 minutes until stable) 1
- Assess for expansion of hematoma
- Consider conservative management with close observation for:
- Small, non-expanding hematomas
- Absence of significant underlying vascular injury
- No signs of compartment syndrome or compression of vital structures 2
Location-Specific Management
Intracranial Hematoma
- Treat as a medical emergency with immediate neuroimaging 1
- Assess using NIHSS for awake patients or GCS for obtunded patients 1
- Evaluate for signs of increased intracranial pressure 1
- For patients on anticoagulants, rapid correction of coagulopathy is essential 1
- Neurosurgical consultation for potential surgical intervention 1
Extremity or Superficial Hematoma
- Apply direct pressure to control bleeding
- Elevate the affected limb if appropriate
- Monitor for signs of compartment syndrome
- Assess neurovascular status distal to the hematoma 1
Abdominal/Retroperitoneal Hematoma
- For patients with significant free intraabdominal fluid and hemodynamic instability, urgent surgery is indicated 1
- For stable patients, CT imaging to determine extent and potential source 1
Special Considerations
Anticoagulation-Related Hematomas
- Evaluate anticoagulant therapy history, platelet count, PTT, and INR 1
- For vitamin K antagonist-related hematomas, rapid INR correction with:
- Vitamin K (5-10 mg IV)
- Prothrombin complex concentrates or fresh frozen plasma 1
Monitoring and Follow-up
- For admitted patients, perform serial clinical assessments
- For intracranial hemorrhage, neurological checks at least hourly for the first 24 hours 1
- Consider repeat imaging if clinical deterioration occurs
Pitfalls to Avoid
- Delaying treatment in expanding hematomas
- Failing to identify and correct underlying coagulopathy
- Missing signs of compartment syndrome or compression of vital structures
- Hyperventilating hypovolemic trauma patients (can decrease cardiac output) 1
- Relying solely on single hematocrit measurements to assess bleeding severity 1
Remember that early identification and management of hematomas is crucial to prevent complications such as expansion, infection, or compression of adjacent structures. The time between injury and definitive treatment should be minimized to improve outcomes 1.