From the Guidelines
Hematoma management should prioritize a restricted volume replacement strategy with a target systolic blood pressure of 80-90 mmHg until major bleeding has been stopped, as recommended in the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.
Key Principles
- The initial approach to hematoma management involves assessing the severity of the bleeding and the patient's overall condition, including the presence of any brain injury 1.
- A restricted volume replacement strategy is crucial in the initial phase following trauma to avoid exacerbating the bleeding 1.
- The use of vasopressors like noradrenaline may be necessary if the restricted volume strategy fails to maintain target arterial pressure 1.
Fluid Management
- Fluid therapy should be initiated with a 0.9% NaCl or balanced crystalloid solution, avoiding hypotonic solutions like Ringer's lactate in patients with severe head trauma 1.
- Colloids should be restricted due to their adverse effect on haemostasis 1.
Blood Transfusion
- Erythrocyte transfusion should aim to achieve a target Hb of 70-90 g/L if necessary 1.
- Cell salvage may be considered in cases of severe bleeding from specific cavities 1.
Surgical Intervention
- Damage-control surgery should be performed in severely injured patients with hemorrhagic shock, signs of ongoing bleeding, coagulopathy, or specific injuries 1.
- Pelvic ring closure and stabilization should be undertaken early in patients with pelvic ring disruption in hemorrhagic shock 1.
Additional Measures
- Tranexamic acid should be administered as soon as possible to trauma patients who are bleeding or at risk of significant bleeding 1.
- Initial coagulation resuscitation should comprise fibrinogen concentrate or cryoprecipitate and pRBC, or FFP in a specific ratio 1.
- Local hemostatic measures, including topical hemostatic agents, should be employed as necessary 1.
From the Research
Hematoma Management Techniques
- Direct pressure remains the most effective "medical" intervention for initial hemorrhage control 2
- Elevate and splint (immobilize) any bleeding extremity or body part as an adjunctive aid for hemorrhage control when used in conjunction with other methods of control, especially direct pressure 2
- Hemostatic dressings, tourniquets, and several new devices can control life-threatening extremity hemorrhage 3
- Manual pressure points technique, such as the femoral and supraclavicular points, can be an applicable and efficient method for temporary hemorrhage control distal to the pressure point 4
Considerations for Specific Patient Groups
- In patients under anticoagulant/antiplatelet treatment, conservative treatment with close follow-up is usually enough for spontaneous abdominal wall hematomas, but surgery is an option that should be decided critically 5
- The decision to restart anticoagulation in patients who present with chronic subdural haematoma whilst on anticoagulation has little empirical evidence to support a decision either way, and more data are required to allow clinicians to make informed decisions 6
General Principles
- Timely application of hemorrhage control interventions is lifesaving, and any amount of blood loss may be detrimental 2
- Early recognition, hospitalization of risky patients, close follow-up of hemodynamic parameters, and patients' response to conservative treatment are key points in hematoma management 5
- Definitive hemostasis for massive internal hemorrhage is best achieved through early surgical intervention 2