What is the management plan for a patient with a right flank hematoma?

Management of Right Flank Hematoma

Immediate stabilization with large-bore IV access, baseline coagulation labs, and aggressive correction of any coagulopathy takes priority, followed by imaging to determine the source and extent of bleeding, with operative intervention reserved for hemodynamically unstable patients or those with expanding hematomas causing tissue compromise. 1, 2

Immediate Assessment and Stabilization

Vascular Access and Laboratory Evaluation

• Establish large-bore IV access immediately, preferably 8-Fr central venous access if the patient shows signs of hemodynamic instability 1, 2
• Draw baseline labs without delay: complete blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), Clauss fibrinogen (not derived fibrinogen, which is unreliable), and cross-match 1, 2
• Consider near-patient coagulation testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available for rapid assessment 1, 2

Hemodynamic Management

• Assess hemodynamic stability by evaluating skin color, heart rate, blood pressure, capillary refill, and conscious level 1
• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is likely adequate 1
• Target mean arterial pressure >65-70 mmHg to maintain organ perfusion 2
• Avoid aggressive hypotensive resuscitation protocols (targeting SBP 80-100 mmHg) used in trauma without brain injury, as these are inappropriate for flank hematomas where adequate perfusion is critical 1, 2

Coagulopathy Correction

• Aggressively correct any coagulopathy immediately, as this directly impacts hemorrhage expansion and mortality 2
• Administer fresh frozen plasma (FFP) 15 mL/kg if fibrinogen <1 g/L or PT/aPTT >1.5 times normal 2
• Maintain platelet count above 75 × 10^9/L 2
• Consider antifibrinolytic agents: tranexamic acid 10-15 mg/kg followed by 1-5 mg/kg/h infusion, particularly if active bleeding is suspected 1, 2

Diagnostic Imaging

Initial Imaging Strategy

• Perform focused assessment with sonography for trauma (FAST) to detect free fluid if the mechanism suggests intra-abdominal extension 1
• Hemodynamically stable patients should undergo computed tomography (CT) to identify the source, extent, and characteristics of the hematoma 1
• Look for specific findings: subcapsular renal hematoma, retroperitoneal extension, active contrast extravasation indicating ongoing bleeding, or mass effect on adjacent structures 3

Imaging Interpretation

• CT findings of active contrast extravasation or significant free fluid with hemodynamic instability mandate urgent intervention 1
• Spontaneous subcapsular renal hematomas may present with flank pain and can be managed conservatively if hemodynamically stable 3
• Chronic expanding hematomas present as slowly growing masses and may mimic soft-tissue neoplasms, requiring biopsy for definitive diagnosis 4

Treatment Strategy

Conservative Management Indications

• Hemodynamically stable patients without active extravasation or tissue compromise should be managed conservatively with serial clinical exams, hemoglobin monitoring, and repeat imaging 1, 3
• Maintain bed rest initially to prevent hematoma expansion 1
• Serial abdominal exams every 4-6 hours to detect expansion or peritoneal signs 1
• Monitor hemoglobin/hematocrit every 6-12 hours initially, then daily as clinically indicated 1
• Repeat CT imaging at 24-48 hours if clinical deterioration occurs or to confirm stability 2

Operative Intervention Indications

• Patients with hemodynamic instability despite adequate resuscitation require urgent surgical exploration 1
• Expanding hematomas causing tissue necrosis from increased pressure require prompt operative evacuation 5
• Active bleeding identified on CT angiography may require angiographic embolization or surgical control 1
• Hematomas causing significant mass effect on adjacent organs warrant surgical decompression 5

Specific Interventions

• For renal subcapsular hematomas: most resolve spontaneously with conservative management over weeks to months 3
• For retroperitoneal hematomas: angiographic embolization is preferred over surgery when technically feasible 1
• For superficial flank wall hematomas: evacuation under local anesthesia in appropriate settings can prevent skin necrosis 5

Post-Acute Management

Monitoring and Follow-up

• Admit to intensive care or step-down unit for continuous monitoring if significant blood loss occurred 2
• Monitor for compartment syndrome signs: severe pain, paresthesias, or diminished pulses 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1, 2
• Correct acid-base abnormalities and electrolyte disturbances 2

Thromboprophylaxis

• Initiate venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 1, 2
• Consider temporary inferior vena cava filtration if thromboprophylaxis is contraindicated due to ongoing bleeding risk 1, 2

Anticoagulation Considerations

• If the patient was on anticoagulation therapy, recognize this significantly increases bleeding risk and complication rates 6
• Reverse anticoagulation according to specific agent protocols before any invasive procedures 2
• Risk-benefit analysis is required before resuming anticoagulation, typically waiting until hematoma stability is confirmed 6

Common Pitfalls

• Do not use derived fibrinogen values; insist on Clauss fibrinogen for accurate coagulation assessment 2
• Avoid applying direct pressure over the hematoma if it could compromise blood flow to the extremity or adjacent structures 1
• Do not delay imaging in stable patients to "observe" clinically, as this may miss opportunities for early intervention 1
• Recognize that normal initial hematocrit does not exclude significant bleeding, as equilibration takes time 1
• Be aware that chronic expanding hematomas can mimic malignancy and may require biopsy for definitive diagnosis 4