What is the treatment for a patient with an internal hip hematoma that is spreading?

Management of Internal Hip Hematoma

The treatment of a spreading internal hip hematoma requires immediate surgical evacuation and control of bleeding, followed by appropriate hemodynamic stabilization and management of coagulation parameters.

Initial Assessment and Stabilization

• Assess hemodynamic stability immediately:

  • Monitor vital signs, especially blood pressure and heart rate
  • Evaluate for signs of hypovolemic shock
  • Establish large-bore IV access (at least two lines)
  • Begin fluid resuscitation with crystalloids

• Laboratory investigations:

  • Complete blood count (CBC) to assess hemoglobin level
  • Coagulation profile (PT, aPTT, fibrinogen)
  • Cross-match for potential blood transfusion
  • Repeat coagulation tests every 30-60 minutes during active bleeding 1

Surgical Management

• Urgent surgical evacuation of the hematoma is the primary treatment for a spreading internal hip hematoma to:

  • Relieve pressure on surrounding structures
  • Identify and control the source of bleeding
  • Prevent further complications such as compartment syndrome

• Surgical approach should include:

  • Adequate exposure of the bleeding site
  • Identification and ligation of bleeding vessels
  • Thorough irrigation of the hematoma cavity
  • Consideration of drain placement to prevent reaccumulation

Blood Product Management

• Transfusion strategy:

  • Maintain hemoglobin at an acceptable level (typically >7-8 g/dL)
  • Consider a high-ratio transfusion strategy (1:1:1 of RBC:plasma:platelets) for massive bleeding 1
  • Target platelet count >75 × 10⁹/L for significant hemorrhage 1
  • Maintain fibrinogen levels >1.5 g/L using cryoprecipitate or fibrinogen concentrate 1

• Pharmacological hemostasis:

  • Consider tranexamic acid (1g loading dose over 10 minutes, followed by 1g over 8 hours) if evidence of hyperfibrinolysis 1
  • Reverse any anticoagulation if present (specific reversal agent depends on the anticoagulant)

Post-Surgical Management

• Close monitoring for:

  • Recurrent bleeding (high mortality risk) 1
  • Hemodynamic stability
  • Adequate pain control
  • Neurovascular status of the affected limb

• Thromboprophylaxis considerations:

  • Once hemostasis is achieved, consider appropriate thromboprophylaxis
  • Mechanical methods (intermittent pneumatic compression devices) initially to avoid increasing bleeding risk 2
  • Pharmacological prophylaxis can be initiated when bleeding risk has decreased 2

Special Considerations

• Patients on anticoagulants:

  • Higher risk of hematoma formation and expansion 3
  • May require specific reversal agents
  • Careful monitoring for rebleeding when anticoagulation is resumed

• Patients with coagulopathies:

  • Require correction of underlying coagulation defects
  • May need specialized hematology consultation
  • Higher risk of complications as seen in patients with conditions like leukemia 4

Complications to Monitor

• Compartment syndrome
• Infection of the hematoma
• Vascular compromise (particularly with large hematomas)
• Pressure-related neuropathy
• Transfusion-related complications (TRALI, TACO) 1

Pitfalls to Avoid

• Delaying surgical intervention for a rapidly expanding hematoma
• Inadequate resuscitation before surgery
• Failure to identify and control all sources of bleeding
• Premature reinitiation of anticoagulation
• Inadequate monitoring for rebleeding post-surgery

Proper management of hip hematomas is crucial as they can significantly increase morbidity and mortality despite adequate treatment 3. Timely intervention and a coordinated approach between surgical, anesthesia, and critical care teams are essential for optimal outcomes.