What are the management options for a scalp hematoma?

Management of Scalp Hematoma

Scalp hematomas should be managed based on their severity, with immediate control of bleeding as the top priority, followed by appropriate assessment and treatment based on hematoma type and associated injuries.

Initial Assessment and Classification

When evaluating a scalp hematoma, it's important to first determine the type:

1. Subgaleal hematoma: Blood collection between the galea aponeurosis and periosteum
2. Subperiosteal hematoma: Blood collection between periosteum and skull
3. Epidural hematoma: Blood collection between skull and dura mater

Immediate Management

For All Scalp Hematomas

• Apply direct pressure to control active bleeding 1
• Consider hemostatic dressings for persistent bleeding 1
• Assess for signs of shock (tachycardia, hypotension, altered mental status)
• Evaluate extent of hematoma using an established grading system 1

For Small, Uncomplicated Scalp Hematomas

• Conservative management with observation
• Cold compresses in the first 24 hours to reduce swelling
• Analgesics for pain control
• Patient education regarding warning signs requiring return

Advanced Management Based on Severity

For Moderate to Large Hematomas

1. Imaging assessment:

   • CT scan for hemodynamically stable patients to rule out underlying skull fracture or intracranial bleeding 1, 2
   • Ultrasound (FAST) can be used for initial assessment in trauma settings 1

2. Laboratory evaluation:

   • Complete blood count
   • Coagulation studies (PT, aPTT, fibrinogen) 1
   • Consider bleeding disorder workup for unusual or recurrent hematomas 3, 4

3. Treatment options:

   • Non-surgical approach: Compression bandaging for contained hematomas without complications 2
   • Surgical drainage: Consider for:
     • Large, expanding hematomas
     • Hematomas causing significant pain
     • Risk of skin necrosis
     • Infected hematomas
     • Hematomas with associated fractures requiring repair 5

For Hematomas with Complications

• For hematomas with signs of infection:

  • Drainage
  • Culture and sensitivity
  • Appropriate antibiotics

• For hematomas with associated skull fracture or intracranial injury:

  • Neurosurgical consultation
  • Possible surgical intervention 5

Special Considerations

Pediatric Patients

• Children with scalp hematomas presenting >24 hours after injury without neurological symptoms may be observed without immediate imaging 6
• Infants require closer monitoring due to higher risk of significant blood loss relative to blood volume 5

Patients with Bleeding Disorders

• Consider underlying coagulopathy in patients with:
  • Disproportionate hematoma to trauma
  • Spontaneous hematoma formation
  • Recurrent hematomas 3, 4
• May require specific factor replacement or other hemostatic therapy

Follow-up Care

• Most uncomplicated scalp hematomas resolve spontaneously within 2-3 weeks
• Monitor for:
  • Signs of infection (increasing pain, redness, warmth)
  • Expansion of hematoma
  • Development of neurological symptoms

Pitfalls to Avoid

1. Underestimating blood loss: Scalp is highly vascular and can lead to significant hemorrhage
2. Missing underlying injuries: Always consider potential for skull fracture or intracranial injury
3. Failure to recognize coagulopathy: Unusual hematomas may be the first presentation of a bleeding disorder 3
4. Premature discharge: Patients with significant mechanism of injury should be observed for development of delayed symptoms

Remember that while most scalp hematomas can be managed conservatively, they require careful assessment to rule out more serious injuries and complications.