How to manage a hematoma in a primary care setting?

Management of Hematoma in Primary Care Setting

In primary care settings, hematomas should be managed based on severity, with early drainage performed as soon as possible after injury to prevent complications and improve patient outcomes. 1

Assessment of Hematoma Severity

Initial evaluation should focus on:

• Location and size of hematoma
• Presence of tension (firm, painful, expanding)
• Risk of skin necrosis (discoloration, decreased capillary refill)
• Underlying anticoagulation status
• Hemodynamic stability

Management Algorithm

1. Non-Severe Hematomas (Small, No Tension)

• Apply cold compresses for first 24-48 hours to reduce swelling
• Elevate affected area if possible
• Provide appropriate analgesia
• Monitor for expansion or complications
• Follow-up within 1 week if not resolving

2. Tension Hematomas with Risk of Skin Necrosis

• Early drainage is critical - ideally within 24 hours of injury 1
• Sterile aspiration technique with appropriate-sized needle
• Consider ultrasound guidance for deeper hematomas
• Apply compression dressing after drainage
• Schedule follow-up within 48-72 hours

3. Large or Complex Hematomas

• Consider referral for surgical evaluation if:
  • Size exceeds 5 cm
  • Evidence of infection
  • Continued expansion despite drainage
  • Compromised tissue viability
  • Failed aspiration attempts

Special Considerations for Anticoagulated Patients

For patients on anticoagulant therapy:

• Do not give additional doses of anticoagulant while bleeding is active 2
• For non-severe bleeding, do not reverse anticoagulation if bleeding can be otherwise controlled 2
• For severe bleeding with hemodynamic instability, consult with the clinician managing anticoagulation regarding reversal strategies 2, 3
• Monitor coagulation parameters (PT/INR, aPTT) in patients on anticoagulants 3
• Consider platelet transfusion for patients on antiplatelet therapy only if bleeding is severe and cannot be controlled by other means 2

Pediatric Considerations

• Scalp hematomas in children typically resolve without intervention 4
• Children presenting >24 hours after injury with isolated scalp hematoma and no neurological symptoms may be managed conservatively 4
• More aggressive monitoring is needed for infants <6 months due to higher risk of complications 4

Red Flags Requiring Urgent Referral

• Rapidly expanding hematoma
• Signs of infection (erythema, warmth, purulent drainage)
• Neurological symptoms (especially with head or spinal hematomas)
• Hemodynamic instability
• Severe pain unresponsive to analgesia
• Compromised distal circulation

Follow-up Care

• Document size, appearance, and location of hematoma
• Provide patient education on warning signs requiring urgent care
• Schedule appropriate follow-up based on severity
• Consider imaging for persistent or concerning hematomas

Pitfalls and Caveats

• Avoid delaying drainage of tension hematomas as this increases risk of skin necrosis 1
• Do not assume all hematomas require drainage - many small hematomas resolve spontaneously
• Be cautious with anticoagulated patients - they may require more aggressive monitoring and management
• Consider underlying causes of spontaneous hematomas (coagulopathy, malignancy)
• Never ignore neurological symptoms with head or spinal hematomas as they may indicate more serious conditions requiring urgent specialist care 5

By following this structured approach, primary care providers can effectively manage most hematomas while appropriately identifying those requiring specialist referral.