What is the initial management for a patient presenting with a hematoma?

Initial Management of Hematoma

For external hematomas with active bleeding, immediately apply direct manual pressure to the bleeding site until hemostasis is achieved; for internal hematomas (intracerebral, spinal, or intraabdominal), prioritize rapid neuroimaging or diagnostic imaging, hemodynamic stabilization, and urgent surgical or interventional consultation based on location and severity. 1, 2

External Hematoma with Active Bleeding

Immediate Hemorrhage Control

• Apply direct manual pressure using gauze or clean cloth to the bleeding site and maintain pressure until bleeding stops 1
• If bleeding continues, add more gauze on top without removing the initial layer 1
• Apply local cold therapy (ice pack) to the wound area to help control bleeding 1

If Direct Pressure Fails

• Use hemostatic dressings as adjunctive therapy if manual pressure is ineffective—these improve effectiveness and shorten time to hemostasis compared to standard dressings 1
• Once bleeding is controlled, apply a pressure dressing with elastic bandage wrapped firmly over gauze to maintain hemostasis 1

Life-Threatening Extremity Bleeding

• Apply a tourniquet only if standard hemorrhage control methods fail to control severe, life-threatening extremity bleeding 1
• Use commercial tourniquets (superior to improvised); if improvising, ensure at least 2 inches wide 1
• Document tourniquet application time and communicate to all healthcare providers 1
• Do not use pressure points or extremity elevation—these are ineffective and delay proper treatment 1

Intracerebral Hemorrhage (ICH)

Emergency Assessment (First 15 Minutes)

• Perform immediate non-contrast CT or MRI to confirm diagnosis, location, and extent of hemorrhage 2
• Calculate baseline severity score using NIHSS (for awake/drowsy patients) or Glasgow Coma Scale (for obtunded/comatose patients) 2
• Assess vital signs every 5-15 minutes until stabilized 2

Critical Laboratory Studies

• Obtain complete blood count, electrolytes, blood urea nitrogen, creatinine, and glucose 2
• Measure PT/INR and aPTT immediately—warfarin-related hemorrhages have increased hematoma volume, greater expansion risk, and increased mortality 2
• Check Clauss fibrinogen (not derived fibrinogen, which is misleading) 2
• Measure serum lactate and base deficit to estimate bleeding severity 2
• Toxicology screen in young/middle-aged patients for cocaine and sympathomimetics 2

Blood Pressure Management (Class C Evidence)

For SBP >200 mmHg or MAP >150 mmHg: Consider aggressive reduction with continuous IV infusion, monitoring BP every 5 minutes 2

For SBP >180 mmHg or MAP >130 mmHg with possible elevated ICP: Monitor ICP and reduce BP with intermittent/continuous IV medications while maintaining cerebral perfusion pressure ≥60 mmHg 2

For SBP >180 mmHg or MAP >130 mmHg without elevated ICP: Target modest reduction (MAP 110 mmHg or BP 160/90 mmHg) using intermittent/continuous IV medications, re-examine clinically every 15 minutes 2

Coagulopathy Reversal (Warfarin-Related ICH)

• Administer IV vitamin K 5-10 mg slowly for all VKA-related ICH 2
• Use prothrombin complex concentrates (PCCs) or fresh frozen plasma for rapid INR correction 2
• FFP requires thawing/cross-matching and carries transfusion reaction risk; PCCs are preferred when available 2

Advanced Imaging for Hematoma Expansion Risk

• Consider CTA or contrast-enhanced CT to identify patients at risk for hematoma expansion (look for "spot sign" indicating contrast extravasation) 2
• CTA, CT venography, or MR angiography can identify underlying structural lesions (vascular malformations, tumors, aneurysms) 2
• Obtain vascular imaging in patients <55 years with lobar hemorrhage and no hypertension history, or if subarachnoid hemorrhage, unusual hematoma shape/location, or disproportionate edema present 2

Neurosurgical Consultation

• Immediate neurosurgical consultation for all ICH patients, particularly those with hemodynamic instability or neurologic deterioration 2

Spinal Epidural Hematoma

Clinical Recognition

• Suspect spinal epidural hematoma in patients presenting with acute, severe, knife-like pain at hemorrhage location ("coup de poignard") followed by progressive paralysis below affected level 3, 4
• Most commonly occurs at cervicothoracic and thoracolumbar regions 3
• High-risk patients: those on anticoagulation, recent spinal procedures, or with coagulopathy 3

Diagnostic Approach

• MRI is the diagnostic method of choice for suspected spinal epidural hematoma 3, 4
• Obtain thorough clinical history—more important than coagulation studies alone for risk assessment 3

Treatment

• Urgent surgical decompression is the treatment of choice for symptomatic spinal epidural hematoma 3, 4
• Time is critical: less severe preoperative symptoms and faster surgical decompression correlate with better recovery (39.6% complete recovery rate overall) 3

Intraabdominal/Pelvic Hematoma

Initial Stabilization

• Secure large-bore IV access (ideally 8-Fr central access in adults) 2
• Administer high FiO2 2
• Actively warm patient and all transfused fluids 2, 5

Diagnostic Imaging

• Perform early focused sonography (FAST) for detection of free intraabdominal fluid in suspected torso trauma 2
• Hemodynamically unstable patients with significant free intraabdominal fluid require urgent surgery 2
• Hemodynamically stable patients with suspected abdominal bleeding after high-energy injuries should undergo CT 2

Pelvic Hematoma Management

• Patients with pelvic ring disruption in hemorrhagic shock require immediate pelvic ring closure and stabilization 2
• If hemodynamic instability persists despite pelvic stabilization, perform early angiographic embolization or surgical bleeding control with packing 2

Resuscitation Targets

• Target systolic BP 80-100 mmHg until major bleeding is controlled in patients without brain injury 2
• Initially use crystalloids; add colloids within prescribed limits 2
• For massive hemorrhage, administer warmed blood products (O-type fastest, then group-specific, then cross-matched) 2, 5

Antifibrinolytic Therapy

• Consider tranexamic acid 10-15 mg/kg bolus followed by 1-5 mg/kg/h infusion in bleeding trauma patients 2, 6
• Infuse no more than 1 mL/minute to avoid hypotension 6

Common Pitfalls

• Do not rely on single hematocrit measurements as isolated markers for bleeding—they may not reflect acute blood loss 2, 5
• Avoid hyperventilation and excessive PEEP in severely hypovolemic patients 2
• Some patients compensate well despite significant blood loss—do not rely solely on BP as indicator 2, 5
• Avoid vasopressors once bleeding control is achieved 2, 7
• For extremity hematomas: prompt recognition and operative evacuation prevents tissue necrosis from increased pressure and ischemia 8