Management of Hematoma
The management of hematoma requires immediate control of bleeding, assessment of severity, and appropriate interventions based on the location, size, and clinical presentation of the blood collection. 1
Initial Assessment and Management
Immediate Actions for Active Bleeding
- Control obvious bleeding points using:
- Direct pressure
- Tourniquets (for extremity bleeding)
- Hemostatic dressings 2
- Administer high concentration oxygen
- Establish large-bore IV access (including central access if needed)
- Obtain baseline blood tests:
- Complete blood count (CBC)
- Prothrombin time (PT)
- Activated partial thromboplastin time (aPTT)
- Fibrinogen levels
- Blood typing and cross-matching 1
Clinical Assessment
- Evaluate for obvious blood loss (visible bleeding, blood on clothing)
- Look for signs of internal bleeding
- Assess vital signs and perfusion (skin color, heart rate, blood pressure, capillary refill, consciousness)
- Determine location and extent of hematoma through appropriate imaging 2
Management Based on Hematoma Type
Massive Hemorrhage/Large Hematoma
Fluid Resuscitation
- Use warmed blood products
- Follow blood product administration in order of availability:
- O-negative (emergency)
- Type-specific
- Cross-matched 2
Blood Component Therapy
Temperature Management
- Actively warm the patient
- Warm all transfused fluids 2
Intracranial Hematoma
- Surgical Evacuation is generally indicated when:
- Epidural hematoma with clot thickness >10 mm or midline shift >5 mm
- Acute subdural hematoma with significant mass effect
- Deteriorating neurological status 3
- Conservative Management may be appropriate for:
- Small epidural hematomas without significant mass effect
- Asymptomatic patients without risk factors
- Close monitoring with repeat imaging is essential 4
Tumor-Associated Hematoma
- Complete diagnostic investigations with contrast-enhanced CT or MRI
- Plan for surgical evacuation of both hematoma and tumor when indicated
- Consider that benign tumors can also cause bleeding (21% of hemorrhagic tumors) 5
Advanced Interventions
Surgical Options
- Craniotomy or craniectomy for intracranial hematomas
- Surgical exploration and vessel ligation for accessible bleeding sites
- Consider damage control surgery for severe cases 2
Interventional Radiology
- Embolization for inaccessible bleeding vessels
- Consider for patients who are poor surgical candidates
Novel Approaches
- Tissue plasminogen activator has been used for intraventricular hematoma lysis in selected cases 6
Post-Acute Management
Monitoring
- Admit to critical care for monitoring after treatment for massive hemorrhage
- Regular assessment of coagulation parameters, hemoglobin, and blood gases
- Monitor wound drains to identify ongoing bleeding 2
Thromboprophylaxis
- Initiate standard venous thromboprophylaxis as soon as bleeding is controlled
- Patients rapidly develop a prothrombotic state after massive hemorrhage
- Consider temporary inferior vena cava filtration in high-risk cases 2, 1
Common Pitfalls and Caveats
Delayed Recognition: Patients may compensate well despite significant blood loss; regular reassessment is crucial.
Coagulopathy Management: Anticipate and prevent coagulopathy; treat aggressively if present.
Normalization of Blood Pressure: Once bleeding is controlled, normalize blood pressure, acid-base status, and temperature, but avoid vasopressors.
Underlying Causes: Always investigate for underlying causes of spontaneous hematomas (tumors, vascular malformations, coagulopathies).
Hospital Protocol: Ensure a well-defined hospital protocol for managing massive hemorrhage that can be mobilized immediately when needed 1.