What to do for a hematoma in an incision site?

Management of Hematoma in Incision Site

A hematoma in an incision site should only be evacuated when there is increased tension on the skin; otherwise, needle aspiration should be avoided due to the risk of introducing skin flora and subsequent infection. 1

Assessment of Hematoma

When a hematoma develops at an incision site, perform a thorough assessment:

• Measure the extent of swelling
• Evaluate pain level
• Assess blood flow in the area proximal and distal to the hematoma
• Check circulation to the adjacent extremity 1
• Determine if there is tension on the skin

Management Algorithm

For Small to Moderate Hematomas:

1. Apply ice for a minimum of 10 minutes 1
2. Apply direct pressure to the site
   • Ensure pressure is applied directly to the bleeding site
   • Take care not to occlude outflow distal to the bleeding site as this could increase intraluminal pressure 1
3. Monitor for resolution
4. Avoid needle aspiration unless absolutely necessary

For Large Hematomas:

1. Apply ice for a minimum of 10 minutes
2. Apply manual pressure for at least 30 minutes 1
3. Only evacuate the hematoma if there is increased tension on the skin 1
4. If evacuation is necessary:
   • Use proper sterile technique
   • Consider surgical evacuation rather than needle aspiration
   • Apply pressure dressing after evacuation

Prevention of Complications

Hematomas in incision sites can lead to serious complications:

• Increased risk of infection
• Potential for wound dehiscence
• Development of stenosis at the site of hematoma 1
• Compression of adjacent structures
• Delayed healing

Special Considerations

• For hematomas associated with cardiovascular implantable electronic devices (CIEDs), evacuation carries significant risk and should only be performed when absolutely necessary due to skin tension 1
• In dialysis access sites, hematomas can potentially compress vessels and lead to thrombosis of the access 1
• Large hematomas may require placement of a temporary drain to prevent reaccumulation 2

Post-Management Care

• Continue to monitor the site for signs of infection
• Apply pressure dressing for 12-24 hours to further decrease risk of hematoma reformation 1
• Educate patient about signs of infection or complications
• Schedule appropriate follow-up to ensure proper healing

Common Pitfalls to Avoid

1. Needle aspiration of hematomas - This introduces risk of infection and should be avoided unless there is significant skin tension 1
2. Using low-molecular-weight heparin in the immediate postoperative period, which predisposes to hematoma formation 1
3. Failing to assess circulation distal to the hematoma
4. Inadequate pressure application during initial management
5. Overlooking potential underlying causes of hematoma (e.g., coagulopathy, medication effects)

By following this evidence-based approach, most incisional hematomas can be managed conservatively with excellent outcomes, while minimizing the risk of infection and other complications.