What is the treatment for a non-infected hematoma?

Treatment for Non-Infected Hematoma

The first-line treatment for non-infected hematomas is conservative management using the RICE protocol (Rest, Ice, Compression, Elevation), with surgical intervention reserved only for specific circumstances such as increased skin tension causing pain, threatening tissue viability, or hemodynamic instability. 1

Conservative Management Approach

Initial Management

• Apply direct pressure to control active bleeding
• Implement RICE protocol:
  • Rest: Limit movement of the affected area
  • Ice: Apply cold therapy for 15-20 minutes several times daily
  • Compression: Use pressure dressing for 12-24 hours after injury
  • Elevation: Keep the affected area elevated above heart level when possible

Cold compression has been shown to reduce hematoma size by approximately 20 cm² over 180 minutes compared to compression alone 1. This approach is particularly effective for superficial hematomas.

Monitoring Phase

• Monitor for signs of expansion or complications
• Patient education is essential - instruct patients to watch for:
  • Fever
  • Increasing pain
  • Signs of inflammation
  • Expanding hematoma

Special Considerations

• For patients on anticoagulation therapy, consider application of topical thrombin to help achieve hemostasis 1
• Avoid low-molecular-weight heparin in the immediate post-injury period as it predisposes to hematoma formation 1
• Avoid needle aspiration when possible as this introduces risk of infection 1

Surgical Intervention

Surgical management should be limited to specific circumstances:

1. Increased tension on the skin causing pain
2. Threatening tissue viability
3. Compromising function of underlying structures
4. Hemodynamic instability unresponsive to supportive measures

For traumatic tension hematomas, early drainage should be performed as soon as possible from the time of injury 2. When debridement and coverage are required, they should be performed in one stage to reduce hospital stay and complications.

Timing of Intervention

The timing of intervention is critical. Evidence shows that patients requiring only hematoma drainage benefit most when treated within the first 24 hours after injury 2. Delayed treatment of large hematomas can lead to skin necrosis due to increased tissue pressure, tissue ischemia, and compartment syndrome in extremities 1.

Location-Specific Management

Vascular Access Hematomas

For hematomas associated with vascular access (e.g., arteriovenous fistulas):

• Surgical intervention is indicated if the hematoma is compromising the lumen of the arterialized vein
• In the absence of luminal compromise, rest the access until the margins of the fistula are well demarcated 3

Intracranial Hematomas

Management differs for intracranial hematomas:

• Epidural hematomas can often be managed nonoperatively in selected patients with good neurological status 4, 5
• For cerebellar hemorrhage, surgical evacuation may improve survival but has not been associated with improved functional outcomes 6

Adjunctive Therapies

• For trauma patients with significant bleeding, tranexamic acid should be administered as soon as possible (within 3 hours) 1
• Target hemoglobin level for erythrocyte transfusion in trauma patients is 70-90 g/L 1

Common Pitfalls to Avoid

1. Delayed recognition: Failure to recognize expanding hematomas can lead to tissue necrosis and compartment syndrome
2. Premature surgical intervention: Not all hematomas require surgical evacuation; many resolve with conservative management
3. Inadequate monitoring: Close follow-up is essential to detect complications early
4. Improper anticoagulation management: Failure to appropriately manage anticoagulation can lead to hematoma expansion
5. Needle aspiration: This should be avoided when possible as it introduces infection risk

Remember that while conservative management is appropriate for most non-infected hematomas, clinical judgment is essential to identify those cases requiring surgical intervention.