What is the initial management for a patient presenting with a hematoma?

Initial Management of Hematoma

The initial management of a patient presenting with a hematoma requires immediate assessment of hemodynamic stability, with direct pressure applied to control bleeding, followed by appropriate diagnostic imaging to determine the extent and location of the hematoma. 1

Assessment and Stabilization

• Assess hemodynamic stability using vital signs (blood pressure, heart rate) to determine the severity of bleeding and need for immediate intervention 1
• Control obvious bleeding points using direct pressure, compression bandages, or tourniquets if necessary 2
• Secure large-bore intravenous access for potential fluid resuscitation in cases of significant bleeding 2
• Evaluate the patient using a structured neurological examination such as the National Institutes of Health Stroke Scale (NIHSS) for awake patients or Glasgow Coma Scale (GCS) for obtunded patients if cerebral hematoma is suspected 1
• Monitor vital signs frequently - every 15 minutes until stabilized for patients with suspected intracranial hemorrhage 1

Diagnostic Evaluation

• Obtain immediate neuroimaging with CT or MRI to confirm diagnosis, location, and extent of hematoma 1
• For suspected intracerebral hemorrhage, non-contrast CT is the gold standard for initial evaluation 1
• Laboratory evaluation should include complete blood count, coagulation studies (PT/INR, aPTT), and assessment of platelet function, especially in patients taking anticoagulant medications 1
• For patients with suspected vascular abnormalities, consider CT angiography, MR angiography, or catheter angiography 1

Management Based on Hematoma Type and Location

Intracerebral Hemorrhage (ICH)

• For hemodynamically stable patients with ICH, use non-invasive management strategies 1
• In hemodynamically unstable patients with no or transient response to resuscitation, perform immediate intervention (surgery or angioembolization) 1
• For patients with large perirenal hematoma (>4 cm) and/or vascular contrast extravasation with deep or complex laceration, perform immediate intervention 1

Soft Tissue Hematoma

• Small, stable hematomas without signs of expansion can be managed conservatively with rest, ice, compression, and elevation (RICE) 3
• Larger hematomas causing significant pain, tissue pressure, or showing signs of skin necrosis should be considered for evacuation 3
• Chronic expanding hematomas may require surgical evacuation to prevent complications such as tissue necrosis 3, 4

Spinal Hematoma

• Symptomatic spinal epidural hematomas typically require urgent surgical decompression of the spinal canal 5
• MRI is the diagnostic method of choice for spinal hematomas 6, 5

Blood Pressure Management

• For patients with ICH, blood pressure should be assessed on initial arrival to the ED and every 15 minutes until stabilized 1
• If systolic blood pressure (SBP) is >200 mmHg or mean arterial pressure (MAP) is >150 mm Hg, consider aggressive reduction with continuous intravenous infusion 1
• If SBP is >180 mmHg or MAP is >130 mm Hg with possible elevated intracranial pressure, consider ICP monitoring while maintaining cerebral perfusion pressure ≥60 mmHg 1
• For patients without evidence of elevated ICP but with SBP >180 mmHg or MAP >130 mm Hg, consider modest reduction to MAP of 110 mm Hg or target BP of 160/90 mmHg 1

Management of Anticoagulation-Related Hematomas

• For patients on vitamin K antagonists (VKAs), rapid correction of INR is recommended 1
• Administration of vitamin K (5-10 mg IV) should be part of all acute VKA reversal strategies 1
• Fresh frozen plasma (FFP), prothrombin complex concentrates (PCCs), or recombinant activated factor VIIa may be considered for rapid reversal 1

Monitoring and Follow-up

• Perform frequent neurological assessments using a validated scale to detect early deterioration 1
• For patients with ICH, repeat imaging should be considered if there is neurological deterioration 1
• Monitor for signs of increased intracranial pressure in patients with intracranial hematomas 1

Common Pitfalls to Avoid

• Delaying surgical intervention for patients requiring urgent bleeding control 1
• Relying solely on blood pressure as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 2
• Failing to recognize and address coagulopathies that may contribute to hematoma expansion 1
• Overlooking the possibility of underlying vascular abnormalities in spontaneous hematomas 1