Should a cold or warm compress be used to treat a hematoma?

Cold Compress for Hematoma Treatment

Apply a cold compress to a hematoma as soon as possible after injury, as cold therapy is more effective than compression alone in reducing hematoma size and blood loss. 1

Primary Treatment Approach

Cold therapy should be the first-line intervention for hematoma management, with the following protocol:

• Apply cold immediately to the hematoma site using an ice pack, instant cold pack, or a bag filled with ice and water surrounded by a damp cloth 1, 2
• Duration: 20-30 minutes per application, repeated 3-4 times daily 1
• Never place ice directly on skin to prevent cold injury 1
• Cold application reduces hematoma size by approximately 20 cm² over 3 hours, compared to only 10 cm² with compression alone 1, 3

Mechanism and Evidence

Cold therapy works through vasoconstriction, which reduces blood flow to the affected area and achieves superior hemostasis compared to compression 2, 3. The evidence demonstrates:

• Blood loss reduction of 610 mL in patients receiving cold compression versus no cold therapy 1
• Extravasation reduced by 357 mL with cold therapy 1
• Significantly smaller hematomas and less pain at 4,48, and 72 hours post-injury with cold application 4
• 90.8% effectiveness in achieving hemostasis for closed bleeding when cold therapy is applied 2

Adjunctive Measures

Combine cold therapy with compression for optimal results:

• Apply compression after or during cold application using direct pressure or a compression wrap 2, 5
• Ensure compression does not compromise circulation by checking distal pulses 1, 5
• Elevate the extremity if feasible, though evidence for elevation alone is limited 1, 5

Critical Pitfalls to Avoid

• Do not use warm compresses for acute hematomas, as there is no evidence supporting heat application and it may worsen bleeding 1
• Avoid prolonged cold application beyond 30 minutes per session to prevent cold injury 1
• In pediatric patients, monitor for hypothermia risk, though localized application to a limited area should not cause systemic cooling 1, 5
• Do not remove initial dressings prematurely to check bleeding status, as this disrupts clot formation 5

When to Escalate Care

Seek immediate medical attention if:

• Hematoma continues to expand despite cold therapy and compression 5
• Distal pulses are absent or diminished, suggesting vascular compromise 5
• Hematoma is near major vessels, which may indicate arterial injury requiring surgical consultation 5
• Severe pain, neurological symptoms, or compartment syndrome signs develop 6

Timing Considerations

Cold therapy is most effective when initiated immediately after hematoma formation:

• Begin cold application as soon as the hematoma is identified 2, 4
• Continue cold therapy for the first 48-72 hours after injury for optimal pain and swelling reduction 4, 7
• After 72 hours, cold therapy provides diminishing returns for established hematomas 4