What are the discharge and follow-up instructions for a patient with a soft tissue hematoma due to extravasation?

Discharge and Follow-up Instructions for Soft Tissue Hematoma with Extravasation

For patients with soft tissue hematoma due to extravasation, immediate management should include elevating the affected limb, applying dry cold compresses for 20 minutes several times daily for 1-2 days, and administering analgesia as needed. 1

Immediate Management Protocol

1. Initial Assessment and Documentation:

   • Document the extravasation incident thoroughly, including:
     • Date and time of extravasation
     • Description of the affected area
     • Approximate amount of extravasated fluid
     • Signs and symptoms reported by patient
     • Photographic documentation if possible 1

2. Immediate Interventions:

   • Elevate the affected limb to reduce swelling
   • Apply dry cold compresses for 20 minutes several times daily for 1-2 days
   • Avoid applying alcohol compresses as they may cause further tissue irritation
   • Administer appropriate analgesia based on pain severity 1

3. Specific Management Based on Extravasated Agent:

   • For anthracyclines: Consider topical DMSO application (99% concentration where available, four drops per 10 cm² of affected skin surface, repeated every 8 hours for 1 week) 1
   • For vesicant agents: Apply specific antidotes as indicated by the type of extravasated drug 1

Discharge Instructions

1. Wound Care:

   • Continue cold application at home (15-20 minutes every 4 hours for 24-48 hours) 2
   • Keep the affected area clean and dry
   • Avoid pressure on the affected area
   • Maintain elevation of the affected limb when possible

2. Pain Management:

   • Take prescribed analgesics as directed
   • For persistent pain, topical DMSO may be considered for its analgesic properties 3
   • For neuropathic pain symptoms, consider topical amitriptyline 1-2% compounded with 0.5% ketamine 3

3. Warning Signs (Instruct patient to seek immediate medical attention if):

   • Increasing pain despite analgesics
   • Progressive swelling or discoloration
   • Numbness or tingling in the affected limb
   • Signs of infection (increased warmth, redness, purulent drainage)
   • Skin breakdown or ulceration 1, 4

Follow-up Care

1. Timing of Follow-up:

   • Initial follow-up within 24-48 hours for severe extravasations
   • Routine follow-up within 7 days for mild to moderate cases
   • Extended monitoring for 3-4 weeks in cases involving vesicant agents 1

2. Assessment During Follow-up:

   • Evaluate for signs of tissue necrosis or progressive damage
   • Document wound healing progress
   • Assess pain levels using validated pain scales 3
   • Evaluate need for surgical intervention if conservative management fails

3. Criteria for Surgical Referral:

   • Unresolved tissue necrosis
   • Pain lasting more than 10 days despite conservative management
   • Large hematomas with poor response to conservative measures
   • Signs of compartment syndrome 1, 5

Special Considerations

1. High-Risk Patients:

   • Patients on anticoagulants or thrombolytics require more frequent monitoring
   • Elderly patients may have delayed healing and require closer follow-up
   • Patients with peripheral vascular disease need more vigilant monitoring 5

2. Central Venous Access Device Extravasation:

   • More serious and requires specialized follow-up
   • May require imaging studies to assess extent of damage
   • Higher risk of mediastinal or pleural involvement 1, 6

Common Pitfalls to Avoid

1. Delayed Recognition: Failure to identify progressive tissue damage can lead to necrosis requiring surgical debridement
2. Inappropriate Thermal Application: Using warm compresses when cold is indicated (or vice versa)
3. Subcutaneous Corticosteroid Injection: Not recommended as it may increase the need for surgical debridement 1
4. Manual Pressure: Avoid applying pressure over the extravasated area as it may spread the extravasated agent 1
5. Inadequate Documentation: Thorough documentation is essential for both clinical and legal purposes 1