What is the initial workup and management for a patient with multiple hematomas?

Initial Workup and Management for Multiple Hematomas

The initial workup for a patient with multiple hematomas should include rapid assessment of hemodynamic status, identification of bleeding sources through imaging, and aggressive resuscitation with blood products while maintaining fibrinogen levels above 1.5 g/L and platelet count above 75 × 10⁹/L. 1, 2

Immediate Assessment

1. Hemodynamic evaluation:

   • Assess vital signs: heart rate, blood pressure, capillary refill, skin color, and consciousness level
   • If patient has palpable peripheral pulse and is conscious, blood pressure is considered adequate 2
   • Look for signs of internal blood loss and obvious external bleeding 1

2. Laboratory investigations:

   • Complete blood count
   • Coagulation profile: prothrombin time (PT), activated partial thromboplastin time (aPTT)
   • Clauss fibrinogen level
   • Blood typing and cross-matching
   • Serum lactate and base deficit (better indicators of shock than single hematocrit) 1, 2

Imaging

1. For hemodynamically unstable patients:

   • Focused Assessment with Sonography in Trauma (FAST) to detect free fluid 1
   • Patients with significant free fluid and hemodynamic instability require urgent surgical intervention 1

2. For hemodynamically stable patients:

   • CT scan to identify source and extent of bleeding 1
   • Ultrasound can be used for follow-up of identified hematomas 3

Resuscitation Strategy

1. Blood product administration:

   • Follow availability order: O-negative, group-specific, cross-matched blood 1, 2
   • Implement high-ratio transfusion strategy (at least 1 unit plasma per 2 units RBC) 2
   • Target fibrinogen levels >1.5 g/L using cryoprecipitate or fibrinogen concentrate 1, 2
   • Maintain platelet count >75 × 10⁹/L 1, 2
   • Actively warm patient and all transfused fluids 1

2. Volume replacement:

   • Target systolic blood pressure of 80-100 mmHg until bleeding is controlled (for patients without brain injury) 1
   • Start with crystalloids, colloids may be added within prescribed limits 1

Management Based on Hematoma Location and Severity

1. For hemodynamically stable hematomas:

   • Conservative management with close monitoring 3
   • Serial hemoglobin/hematocrit checks
   • Monitor coagulation parameters every 30-60 minutes during active bleeding 2

2. For expanding or hemodynamically significant hematomas:

   • Surgical intervention for direct bleeding control 1
   • Consider angiographic embolization for ongoing bleeding despite other measures 1, 3
   • For pelvic hematomas with ring disruption, immediate pelvic ring closure and stabilization 1

3. For patients on anticoagulants:

   • Reverse anticoagulation based on specific agent:
     • For warfarin: Prothrombin Complex Concentrate (PCC) dosing based on INR and intravenous vitamin K (5-10 mg) 1
     • For heparin: Protamine (1 mg reverses 100 units of heparin) 1

Ongoing Management

1. Monitoring:

   • Admit to critical care for close observation 1
   • Regular assessment of coagulation parameters, hemoglobin, and blood gases 1, 2
   • Monitor for signs of rebleeding 2

2. Coagulopathy management:

   • Anticipate and prevent dilutional coagulopathy with early FFP infusion 1
   • Consider antifibrinolytic agents (tranexamic acid 10-15 mg/kg followed by infusion of 1-5 mg/kg/h) 1
   • Correct hypocalcemia and hypomagnesemia associated with massive transfusions 2

3. Post-bleeding care:

   • Initiate standard venous thromboprophylaxis once bleeding is controlled 1
   • Consider temporary inferior vena cava filtration in high-risk cases 1

Common Pitfalls and Caveats

1. Don't underestimate blood loss - patients may compensate well despite significant hemorrhage 1

2. Don't delay resuscitation while waiting for diagnostic procedures 2

3. Don't rely on single hematocrit measurements as isolated markers for bleeding 1

4. Avoid vasopressors if possible as they may worsen bleeding 1

5. Don't forget about consumptive coagulopathy - particularly in obstetric hemorrhage, trauma with head injury, and sepsis 1

6. Don't overlook anticoagulant medications - patients on anticoagulants have greater risk of coagulopathic bleeding 1

7. Establish clear communication - appoint a team leader to coordinate care 2

By following this structured approach to the workup and management of multiple hematomas, clinicians can effectively identify the source of bleeding, implement appropriate resuscitation measures, and minimize morbidity and mortality associated with significant blood loss.