What is the management for a large gluteal hematoma, including the role of computed tomography (CT)-guided embolization?

Management of Large Gluteal Hematoma

For large gluteal hematomas with ongoing bleeding or hemodynamic instability, CT angiography should be performed immediately to identify active extravasation, followed by catheter-directed angiographic embolization as the definitive treatment. 1, 2

Initial Assessment and Stabilization

Hemodynamic status determines the urgency of intervention:

• Apply direct pressure to the gluteal region and establish large-bore IV access immediately in patients with signs of active hemorrhage 1
• Activate major hemorrhage protocol if the patient shows signs of shock (hypotension, tachycardia, altered mental status) 3
• Assess for hemorrhagic shock using serum lactate and base deficit, which are superior to single hematocrit measurements for estimating bleeding severity 3
• Administer high-flow oxygen and begin resuscitation with warmed blood products (not crystalloids alone) if hemodynamically unstable 1

Diagnostic Imaging

CT angiography (CTA) is the diagnostic modality of choice:

• Perform CTA immediately in hemodynamically stable patients to identify the bleeding source and guide intervention 3, 2
• Look for contrast extravasation indicating active bleeding, most commonly from branches of the superior gluteal artery or deep femoral artery 4, 2
• CTA identifies pseudoaneurysms that may develop after blunt trauma or iatrogenic injury, even without bony injury 2

Definitive Management: Angiographic Embolization

Catheter angiography with embolization is the preferred definitive treatment:

• Perform selective angiographic embolization for patients with identified arterial bleeding on CTA or ongoing hemodynamic instability 1, 2
• Target the superior gluteal artery or its branches, which are the most common bleeding sources in gluteal hematomas 2, 5
• Use microcoils as the primary embolic agent, though Onyx can be considered for small vessel bleeding where selective access is challenging 4
• Embolize in a superselective, distal-to-proximal fashion to minimize collateral "back door" rebleeding 3

Critical Caveat: Gluteal Muscle Necrosis Risk

Be aware that angiographic embolization carries significant risk of gluteal muscle ischemia and necrosis:

• Gluteal muscle necrosis occurs with high incidence after transcatheter embolization, particularly with non-selective techniques 6
• MRI studies demonstrate ischemic damage in the majority of patients 1-4 weeks post-embolization 6
• Complications include soft tissue infection, skin necrosis, and sepsis requiring debridement surgery 6
• Use unilateral selective embolization rather than bilateral or non-selective techniques to minimize this risk 6

Alternative and Adjunctive Measures

For specific clinical scenarios:

• CT-guided drainage with pigtail catheter placement can be considered for large, symptomatic hematomas causing unbearable pain, potentially combined with tissue plasminogen activator (t-PA) injection 4
• Surgical evacuation and packing should be reserved for patients who fail angiographic embolization or when embolization is not available 3
• Administer tranexamic acid (1 g IV over 10 minutes, then 1 g over 8 hours) if given within 3 hours of bleeding onset for mortality benefit 1

Coagulopathy Management

Correct coagulopathy aggressively:

• Maintain fibrinogen >1 g/L and platelet count >75 × 10⁹/L 3, 1
• Administer fresh frozen plasma (15 ml/kg) early if PT/aPTT >1.5 times normal 3
• Use fibrinogen concentrate or cryoprecipitate for rapid fibrinogen replacement in established coagulopathy 3

Post-Intervention Monitoring

After bleeding control:

• Admit to critical care for monitoring of coagulation parameters, hemoglobin, and vital signs 1
• Start venous thromboprophylaxis as soon as hemostasis is secured, as patients develop a prothrombotic state after massive hemorrhage 3, 1
• Monitor for delayed complications including abscess formation, which can occur weeks after the initial injury, particularly with iatrogenic causes 5

Important pitfall: Do not delay definitive intervention with repeated imaging or conservative management in hemodynamically unstable patients—proceed directly to angiography with intent to embolize 3.