What is the best treatment for hematomas?

Best Treatment for Hematomas

The best treatment for hematomas depends on the location, size, and clinical presentation, with localized cold therapy with compression being the recommended first-line treatment for superficial hematomas, while surgical evacuation is indicated for specific intracranial hematomas with significant mass effect or neurological deterioration. 1

General Approach to Hematoma Management

Superficial/Small Hematomas

• First-line treatment:
  • RICE protocol (Rest, Ice, Compression, Elevation) 1
  • Cold therapy with compression reduces hematoma size by approximately 20 cm² over 180 minutes compared to compression alone 1
  • Apply direct pressure to control active bleeding 1

Intracranial Hematomas

Treatment decisions should be based on:

• Location (supratentorial vs. cerebellar)
• Size and volume
• Degree of mass effect
• Neurological status (GCS score)
• Presence of hydrocephalus

Cerebellar Hematomas

• Surgical evacuation is indicated for:

  • Complete effacement of the fourth ventricle (Grade III compression) 2
  • Grade II compression with deteriorating GCS score in the absence of untreated hydrocephalus 2
  • Impending brainstem compression 3
  • Clinical hydrocephalus with fourth ventricle obstruction 3

• Conservative management may be appropriate for:

  • Hematomas with Grade I or II compression of the fourth ventricle with stable GCS scores >13 2
  • Large hematomas (>3 cm) if the fourth ventricle is not totally obliterated 2

Supratentorial Hematomas

• Surgical options include:
  • Decompressive craniectomy with or without hematoma evacuation for patients in coma, with large hematomas causing significant midline shift, or with elevated ICP refractory to medical management 3
  • Endoscopic aspiration (especially beneficial for lobar hematomas and patients <60 years) 1
  • Stereotactic aspiration with thrombolytic therapy 1

Special Considerations

Tension Hematomas

• Early drainage should be performed as soon as possible from the time of injury 4
• When debridement and coverage surgery are required, they should be performed in one stage to reduce hospital stay and complications 4

Muscle Hematomas

Treatment follows a staged approach:

1. Super-acute stage: Control bleeding and minimize hematoma size
2. Acute stage: Restore pain-free range of motion
3. Subacute stage: Functional rehabilitation
4. Recovery stage: Gradual return to normal activity 5

Epidural Hematomas

• Small, asymptomatic epidural hematomas may be managed conservatively with careful neurological observation and repeat CT scans 6
• Higher risk of deterioration requiring evacuation if:
  • Skull fracture overlying a major vessel or sinus
  • Diagnosis made within 6 hours of trauma 6

Pitfalls and Caveats

• For intracranial hematomas:

  • Delaying surgical evacuation in patients with cerebellar hematomas and Grade III fourth ventricular compression can lead to rapid deterioration 2
  • Patients with GCS scores <8 and Grade III fourth ventricular compression have poor outcomes despite treatment 2
  • Decompressive craniectomy may reduce mortality but has uncertain effects on functional outcomes 3

• For superficial hematomas:

  • Failure to recognize tension hematomas can lead to skin necrosis 4
  • In patients on anticoagulation, hematomas may continue to expand if bleeding is not adequately controlled 4

• For traumatic bleeding:

  • In trauma patients with significant bleeding, tranexamic acid should be administered as soon as possible (within 3 hours) 3
  • Target hemoglobin of 70-90 g/L if erythrocyte transfusion is necessary 3