How is a hematoma treated?

Treatment of Hematoma

The treatment of a hematoma depends critically on its location, size, and clinical presentation, with management ranging from conservative observation to urgent surgical evacuation based on specific clinical criteria.

Initial Assessment and Risk Stratification

The first priority is determining whether the hematoma poses an immediate threat to tissue viability or neurological function:

• Control obvious bleeding with direct pressure, tourniquets, or hemostatic dressings as appropriate 1
• Assess for signs of increased tissue tension that could compromise overlying skin perfusion, as hematomas can cause tissue necrosis through increased pressure and cellular ischemia 2
• Evaluate neurological status in cases of intracranial or spinal hematomas, as location significantly impacts risk of herniation and outcome 3
• Obtain baseline coagulation studies including PT, aPTT, and fibrinogen levels 1

Location-Specific Management

Cardiovascular Device Pocket Hematomas

Hematomas complicating cardiac device placement should only be evacuated when there is increased tension on the skin; otherwise, needle aspiration must be avoided due to infection risk 1:

• Prevention is paramount through meticulous hemostasis, pocket packing with antibiotic-soaked sponges, and topical thrombin application 1
• Apply pressure dressing for 12-24 hours post-procedure 1
• Avoid low-molecular-weight heparin in the immediate postoperative period as it predisposes to hematoma formation 1
• If evacuation is required due to skin tension, formal surgical drainage is preferred over needle aspiration to prevent introducing skin flora 1

Extremity Hematomas

Prompt operative evacuation should be performed for extremity hematomas causing tissue tension to prevent skin necrosis 2, 4:

• Small hematomas (averaging 0.63% total body surface area) may only require debridement without grafting 4
• Early drainage within 24 hours of injury provides optimal outcomes 4
• When debridement and skin coverage are necessary, perform both procedures in one stage to reduce hospital stay and medical complications 4
• Two-stage procedures result in significantly higher complication and mortality rates 4

Intracranial Hematomas

Surgical evacuation timing depends on hematoma size, location, and neurological status 1:

• Life-threatening hematomas require emergency craniotomy for decompression 1
• For stable patients with acute subdural hematomas ≥7mm thickness and Glasgow Coma Scale ≥13, minimally invasive approaches like twist-drill craniostomy with fibrinolytic irrigation may be considered 5
• Temporal or temporoparietal hematomas >30cc carry highest risk (64%) of tentorial herniation and require prompt surgical consideration 3
• Complete hematoma removal is the goal; intraoperative or postoperative angiography confirms complete obliteration 1

Spinal Hematomas

Surgical decompression is the treatment of choice for spinal hematomas, with timing critical for neurological recovery 6:

• MRI is the diagnostic examination of first choice 6
• The less severe the preoperative symptoms and the faster surgical decompression is performed, the better the chances for complete recovery 6
• 39.6% of patients achieve complete recovery with appropriate treatment 6
• Close neurological monitoring is essential, particularly in patients on anticoagulation 6

Massive Hemorrhage Protocol

When hematoma is associated with ongoing massive bleeding:

• Establish large-bore IV access (8-Fr central access preferred) 1
• Initiate damage control resuscitation with warmed blood products in FFP:pRBC ratio of at least 1:2 1
• Administer tranexamic acid 1g over 10 minutes, followed by 1g over 8 hours if given within 3 hours of injury 1
• Consider surgical intervention, angioembolization, or REBOA for ongoing hemorrhage 1
• Actively warm the patient to prevent hypothermia-induced coagulopathy 1

Critical Pitfalls to Avoid

• Never perform needle aspiration of device pocket hematomas unless there is skin tension requiring evacuation—this introduces infection risk with 100% relapse rate in conservative management of infected pockets 1
• Do not delay surgical decompression of spinal hematomas, as neurological outcome directly correlates with speed of intervention 6
• Avoid staged procedures for extremity hematomas requiring debridement and coverage—single-stage surgery reduces complications 4
• Do not assume anticoagulation alone causes hematomas—there must be an additional predisposing factor or increased venous pressure 6