Management of Hematoma at an Incision Site
Hematomas at incision sites should be managed conservatively with the RICE protocol (Rest, Ice, Compression, Elevation) as first-line treatment, with surgical evacuation reserved only for cases with increased skin tension or hemodynamic instability. 1
Conservative Management Approach
Conservative management is the mainstay of treatment for most incisional hematomas and includes:
- Application of cold therapy (ice packs): Apply for 15-20 minutes at a time to reduce bleeding and minimize hematoma formation 1
- Compression: Apply a pressure dressing for 12-24 hours after skin closure to decrease the risk of hematoma expansion 2
- Elevation: Elevate the affected area when possible to reduce swelling
- Rest: Limit activity that could increase bleeding or disrupt the healing process
Cold compression therapy has been shown to reduce hematoma size by approximately 20 cm² over 180 minutes compared to compression alone, making it particularly effective 1.
When to Consider Surgical Evacuation
Surgical intervention should be limited to specific circumstances:
- Increased tension on the skin causing pain or threatening tissue viability 2
- Hemodynamic instability that fails to respond to supportive measures 1
- Progressive expansion despite conservative management
- Signs of compartment syndrome or tissue ischemia 1
Important Cautions
- Avoid needle aspiration of hematomas when possible, as this introduces the risk of introducing skin flora into the pocket and subsequent development of infection 2
- Monitor closely for signs of infection, expansion, or skin necrosis
- Recognize complications early: Delayed treatment of large hematomas can lead to skin necrosis due to increased tissue pressure and tissue ischemia 1
Pain Management
For pain control, consider:
- Multimodal analgesia including non-opioid analgesics 1
- Regional anesthesia techniques for severe pain when appropriate 1
Special Considerations
Anticoagulated Patients
- For patients on anticoagulation therapy, consider application of topical thrombin to help achieve hemostasis 2
- Avoid low-molecular-weight heparin in the immediate postoperative period as it predisposes to hematoma formation 2
Tranexamic Acid Consideration
For significant bleeding, tranexamic acid may be considered as it works by preventing the dissolution of hemostatic fibrin by plasmin 3. It should be administered as soon as possible (within 3 hours) in cases with significant bleeding 1.
Follow-up Care
Patient education is essential for early identification of complications. Instruct patients to contact their physician if they develop:
- Fever
- Increasing pain
- Signs of inflammation at the incision site
- Expanding hematoma 2
By following these guidelines, most incisional hematomas can be managed effectively while minimizing the risk of complications and optimizing patient outcomes.