Treatment for Large Hematoma
The treatment for a large hematoma requires immediate control of bleeding points through direct pressure, tourniquets, or hemostatic dressings, followed by appropriate fluid resuscitation with warmed blood and blood components when necessary. 1
Initial Assessment and Management
Immediate Actions
- Control obvious bleeding points using:
- Direct pressure
- Tourniquets (if appropriate)
- Hemostatic dressings
- Establish large-bore IV access (largest possible, including central access)
- Obtain baseline blood tests:
- Full blood count (FBC)
- Prothrombin time (PT)
- Activated partial thromboplastin time (aPTT)
- Clauss fibrinogen
- Cross-match
- Perform rapid clinical assessment:
- Look for injury patterns
- Assess visible blood loss
- Check for signs of internal bleeding
- Evaluate vital signs (heart rate, blood pressure, capillary refill, skin color, consciousness) 1
Fluid Resuscitation
- For massive hemorrhage, use warmed blood and blood components
- Blood product administration priority:
- Group O (quickest)
- Group-specific
- Cross-matched blood
- Consider high-ratio transfusion strategy of 1:1:1 (plasma:platelets:PRBCs) for severely traumatized patients 2
- Actively warm the patient and all transfused fluids 1
Diagnostic Imaging
- Rapid access to imaging is essential:
- Ultrasound
- Radiography
- CT scan (if patient is stable enough)
- Use focused assessment with sonography for trauma (FAST) scanning when appropriate 1
Definitive Management
Surgical Intervention
- Surgery must be considered early for large hematomas causing significant symptoms or complications
- In some cases, "damage control" surgery may be necessary
- For spinal epidural hematomas, decompressive laminectomy may be required in selected cases, though conservative management with factor replacement may be sufficient in certain patients 3
- For intracerebral hematomas, stereotactic aspiration may be beneficial in selected cases 4
Non-surgical Management
- Once bleeding is controlled:
- Normalize blood pressure, acid-base status, and temperature
- Avoid vasopressors
- Provide active warming
- Treat coagulopathy aggressively if present 1
- Monitor for signs of rebleeding or hematoma expansion
Management of Coagulation Issues
- Prevent dilutional coagulopathy with early infusion of fresh frozen plasma (FFP)
- Target fibrinogen levels >1 g/L
- Consider viscoelastic testing (TEG, ROTEM) for rapid evaluation of hemostasis
- Maintain minimum platelet count of 75×10⁹/L 2
Post-Acute Care
- Admit to critical care area for monitoring and observation
- Monitor:
- Coagulation parameters
- Hemoglobin
- Blood gases
- Wound drains to identify ongoing bleeding 1
- Initiate standard venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 1, 2
Special Considerations
- For patients with traumatic brain injury, maintain higher platelet transfusion threshold (100,000/mm³) 2
- For subgaleal hematomas, complete surgical evacuation may be necessary in severe cases 5
- For spinal hematomas, magnetic resonance imaging is the examination of choice, and early surgical decompression offers the best chance for complete recovery 6