What is the treatment for hematoma?

Treatment of Hematoma

The treatment of hematoma depends critically on location and size, with most superficial hematomas managed conservatively using cold therapy and compression, while intracranial and large complicated hematomas require specific interventions based on anatomical location and clinical severity.

Initial Assessment and Management

Superficial/Peripheral Hematomas (First-Line Conservative Approach)

• Apply localized cold therapy with or without compression during the first 24-48 hours to reduce bleeding, limit hematoma expansion, and decrease inflammation 1, 2, 3
• Implement the RICE protocol: rest (avoid activities stressing the injured area), ice application, compression to limit swelling, and elevation to reduce edema 3
• Provide appropriate analgesics for pain management as needed 3
• Evaluate hemodynamic stability immediately, as large hematomas can cause substantial blood loss requiring fluid resuscitation 2, 4

Anticoagulation Management

• Discontinue or reverse anticoagulation therapy after weighing risks versus benefits in patients on anticoagulant/antiplatelet medications 2, 4
• Small retropharyngeal hematomas from anticoagulation can be managed conservatively if the airway is not seriously compromised 5
• Investigate for underlying coagulation disorders if hematomas are recurrent 2

Location-Specific Treatment Algorithms

Intracranial Hemorrhage (ICH)

Supratentorial ICH:

• Conservative management remains standard for most patients, as randomized trials (including STICH) showed no overall benefit from routine craniotomy 1
• Consider minimally invasive approaches for specific subgroups: lobar hematomas in patients <60 years old showed better outcomes with endoscopic evacuation (mortality 42% vs 70% with medical management) 1
• Image-guided para-corticospinal tract approach may improve functional independence when surgery is indicated, with 32% favorable outcomes versus 17.4% with conservative treatment 6

Intraventricular Hemorrhage (IVH):

• Ventriculostomy with intraventricular thrombolytic therapy (rtPA or urokinase) reduces mortality from 47% to 23% compared to ventriculostomy alone 1
• Administer rtPA 1-4 mg every 8-12 hours through the ventricular catheter 1

Posterior Fossa ICH:

• Surgical decompression is indicated for hematomas causing direct brainstem compression or hydrocephalus - this is so beneficial it cannot be ethically evaluated in RCTs 1
• External ventricular drainage for associated hydrocephalus 1

Abdominal Wall Hematoma

• Percutaneous mechanical thrombectomy is effective for persistent post-surgical hematomas, offering reduced operative time and minimal tissue trauma 4
• Apply damage control principles in hemorrhagic shock: address ongoing bleeding, coagulopathy, and hypothermia first 4
• Consider skin-only closure with delayed reconstruction when definitive fascial closure cannot be achieved 4

Muscle Hematomas (e.g., Gracilis)

• Initial RICE protocol as described above 3
• For large hematomas causing significant pain or functional impairment, consider ultrasound-guided aspiration 3
• Monitor closely for compartment syndrome, which requires immediate surgical intervention 3

Subgaleal Hematoma

• Cold compresses for 24-48 hours 2
• Endoscopic-assisted evacuation for complex cases ensures complete removal while minimizing tissue trauma 2

Spinal Hematoma

• Surgical decompression is the treatment of choice - timing is critical for recovery 7
• The less severe preoperative symptoms and the faster decompression occurs, the better the chance for complete recovery (39.6% complete recovery rate overall) 7
• MRI is the examination of choice for diagnosis 7

Surgical Indications Summary

Proceed with surgical evacuation when:

• Intracranial hematoma with mass effect causing herniation risk 1
• Posterior fossa hemorrhage with brainstem compression 1
• Hydrocephalus requiring ventricular drainage 1
• Large peripheral hematomas causing significant functional impairment 3
• Spinal hematoma with progressive neurological deficit 7
• Compartment syndrome 3

Common Pitfalls to Avoid

• Do not routinely perform craniotomy for supratentorial ICH - evidence does not support improved outcomes in most patients 1
• Avoid premature surgical intervention for small, stable hematomas that can resolve with conservative management 2, 5
• Do not delay spinal hematoma decompression - neurological recovery is time-dependent 7
• Recognize that minimally invasive approaches may have prolonged indwelling catheters that increase infection risk 4

Adjunctive Therapies

• Hyaluronidase injection (1,500 IU with 2 mL normal saline subcutaneously in crisscross pattern) can improve post-traumatic hematoma and prevent fibrosis progression when used early 8
• This approach is particularly useful for facial contusions to prevent fibrotic complications 8