Does an 84-year-old patient with a 4.6x9.7x4.7 cm right gluteal intramuscular hematoma after trauma, not on anticoagulants (blood thinners), require admission for observation if no active extravasation is noted on the computed tomography angiography (CTA) scan?

Management of Gluteal Intramuscular Hematoma in an 84-Year-Old Trauma Patient

An 84-year-old patient with a 4.6x9.7x4.7 cm gluteal intramuscular hematoma and no active extravasation on CTA can be safely discharged without admission for observation, provided they are hemodynamically stable, have a normal neurologic examination, and have adequate social support for home monitoring.

Initial Assessment and Risk Stratification

Hemodynamic Stability Assessment

• Geriatric trauma patients require modified vital sign thresholds: systolic blood pressure <110 mmHg (rather than <90 mmHg) and heart rate >90 bpm should trigger concern for occult shock 1
• Perform early blood gas analysis for baseline base deficit or lactate assessment, as these are sensitive markers for estimating the extent of bleeding and shock even when vital signs appear stable 1
• Serial base deficit and lactate measurements provide early objective evaluation of response to resuscitation and are reliable prognostic indicators 1

Imaging Interpretation

• CTA has superior sensitivity to conventional angiography for detecting active bleeding, capable of identifying bleeding rates as low as 0.3 mL/min 1
• The absence of active contrast extravasation on CTA indicates no ongoing arterial bleeding at the time of imaging 1
• For intramuscular hematomas without active extravasation, the risk of requiring urgent intervention is very low 1

Decision Algorithm for Admission vs Discharge

Criteria Supporting Safe Discharge (All Must Be Present)

• Hemodynamically stable with systolic blood pressure ≥110 mmHg and heart rate <90 bpm 1
• Normal or normalizing base deficit (>-5 mmol/L) and lactate levels 1
• No active contrast extravasation on CTA 1
• Stable or decreasing hematoma size if serial imaging performed 2
• Adequate social support for home observation with clear discharge instructions 3
• No other injuries requiring admission 1

Criteria Requiring Admission

• Hemodynamic instability despite initial resuscitation (systolic BP <110 mmHg, HR >90 bpm, or requiring vasopressors) 1
• Persistent base deficit <-5 mmol/L or elevated lactate despite resuscitation 1
• Declining hemoglobin requiring transfusion 1
• Concern for compartment syndrome or neurovascular compromise 1
• Inadequate social support or inability to return for follow-up 3

Special Considerations for Elderly Patients

Age-Related Risk Factors

• Advanced age (≥75 years) is an independent risk factor for complications and mortality in trauma patients 1
• Elderly patients may have occult hypoperfusion despite normal-appearing vital signs, requiring closer monitoring of base deficit and lactate trends 1
• The threshold for trauma protocol activation and intensive monitoring should be lower in geriatric patients 1

Coagulation Status

• Although this patient is not on anticoagulants, verify coagulation parameters (PT/INR, aPTT, platelet count) as elderly patients may have undiagnosed coagulopathy 1
• Factor XIII deficiency, though rare, can contribute to enlarging hematomas even without overt coagulopathy 4

Observation Protocol if Admission Chosen

Monitoring Parameters

• Serial clinical examinations with vital signs every 2-4 hours 1
• Serial hemoglobin measurements every 6-8 hours for the first 24 hours 1
• Continuous base deficit and lactate monitoring to detect occult hypoperfusion 1
• Monitor for signs of compartment syndrome: increasing pain, paresthesias, or motor weakness 1

Repeat Imaging Indications

• Repeat imaging is NOT routinely indicated if the patient remains clinically stable with normal vital signs and laboratory parameters 1, 3
• Obtain repeat CT only if clinical deterioration occurs: worsening pain, expanding mass, hemodynamic instability, or declining hemoglobin 1, 3, 2
• Most hematoma expansion occurs within the first 6-24 hours after injury 2

Discharge Instructions and Follow-Up

Patient Education

• Provide clear written instructions about warning signs: increasing pain, swelling, numbness, weakness, dizziness, or syncope 3
• Instruct patient to avoid anticoagulants and antiplatelet agents unless specifically indicated and cleared by their physician 3
• Advise activity modification and avoidance of strenuous activity for 2-4 weeks 4

Outpatient Follow-Up

• Arrange follow-up within 3-5 days with primary care physician or trauma clinic 3
• Consider outpatient assessment of fall risk and need for physical therapy in elderly patients 3
• Most intramuscular hematomas resolve spontaneously within 3-5 months without intervention 4

Common Pitfalls to Avoid

• Failing to use geriatric-specific vital sign thresholds (BP <110 mmHg rather than <90 mmHg) may result in missed occult shock 1
• Relying solely on initial hemoglobin/hematocrit without serial measurements, as initial values do not accurately reflect acute blood loss 1
• Discharging patients without adequate social support or clear return precautions, particularly in the elderly population 3
• Performing unnecessary repeat imaging in stable patients, which increases costs and radiation exposure without clinical benefit 1, 3
• Overlooking base deficit and lactate as sensitive markers of ongoing bleeding and tissue hypoperfusion in elderly patients with normal vital signs 1