What is the best approach for correcting a hematoma (collection of blood outside of blood vessels) in the scalp, eyelid, or forehead?

Management of Scalp, Eyelid, and Forehead Hematomas

Initial Assessment and Treatment Approach

For most scalp, eyelid, and forehead hematomas, conservative management with RICE protocol (Rest, Ice, Compression, Elevation) is the recommended first-line treatment. 1

Conservative Management (First-Line)

1. Direct pressure application

   • Apply firm, direct pressure to control active bleeding
   • Maintain pressure for at least 10-15 minutes

2. Cold therapy

   • Apply ice packs immediately to reduce bleeding and hematoma formation 1
   • Cold compression has been shown to reduce hematoma size by approximately 20 cm² over 180 minutes compared to compression alone 1
   • Apply for 15-20 minutes at a time with short breaks to prevent tissue damage

3. Compression

   • Apply a pressure dressing for 12-24 hours after initial management 1
   • Use non-elastic bandage for direct compression of subgaleal hematomas 2

4. Elevation

   • Keep the head elevated to reduce hydrostatic pressure and minimize swelling

Indications for Surgical Intervention

Surgical intervention is indicated in the following scenarios:

1. Large hematomas causing significant mass effect

   • Hematomas causing neurological deterioration
   • Large hematomas with significant midline shift 1

2. Expanding hematomas

   • Hematomas that continue to enlarge despite conservative management
   • Initial hematoma volume and degree of midline shift are independent risk factors for hematoma progression 3

3. Compromised tissue viability

   • Delayed treatment of large hematomas can lead to skin necrosis due to increased tissue pressure and tissue ischemia 1

4. Cosmetic concerns

   • Persistent large hematomas causing significant cosmetic deformity

Surgical Approaches

1. Minimally invasive evacuation

   • Endoscopic or stereotactic aspiration is beneficial, especially for patients with moderate-sized hematomas 4, 1
   • Provides better functional outcomes compared to conventional craniotomy 4

2. Needle aspiration

   • Generally avoided when possible due to risk of introducing skin flora and subsequent infection 1
   • May be considered for rapidly expanding hematomas causing significant pressure

3. Incision and drainage

   • For large, fluctuant hematomas that fail to resolve with conservative management
   • Small incision at the dependent portion of the hematoma

4. Conventional craniotomy

   • Reserved for large intracranial hematomas with significant mass effect
   • May be necessary when minimally invasive approaches are not feasible

Special Considerations

Eyelid Hematomas

• Require careful monitoring due to risk of vision compromise
• Ophthalmology consultation recommended for:
  • Rapidly expanding periorbital hematomas
  • Visual disturbances
  • Proptosis or restricted eye movements

Anticoagulation Therapy

• For patients on anticoagulation therapy:
  • Consider application of topical thrombin to help achieve hemostasis 1
  • May require reversal of anticoagulation before surgical intervention for large hematomas 1
  • Avoid low-molecular-weight heparin in the immediate postoperative period as it predisposes to hematoma formation 1

Monitoring and Follow-up

• Close monitoring for:

  • Expansion of hematoma
  • Signs of infection (fever, increasing pain, erythema)
  • Neurological deterioration
  • Skin necrosis

• Patient education:

  • Instruct patients to contact their physician if they develop fever, increasing pain, signs of inflammation, or an expanding hematoma 1

Conclusion

The management of scalp, eyelid, and forehead hematomas primarily involves conservative measures with the RICE protocol. Surgical intervention should be reserved for large, expanding hematomas causing significant symptoms or cosmetic concerns. The approach should be tailored based on the size, location, and progression of the hematoma, with minimally invasive techniques preferred when surgical intervention is necessary.