How to manage a large complex hematoma in the right groin with evidence of blood clot?

Management of Large Complex Groin Hematoma with Blood Clot

Conservative management with close monitoring is the primary approach for this large groin hematoma, reserving surgical intervention only for hemodynamic instability, expanding hematoma, or neurovascular compromise.

Immediate Assessment and Stabilization

Hemodynamic Evaluation

• Assess vital signs immediately (heart rate, blood pressure, capillary refill, conscious level) to determine if the patient is compensating adequately despite the 500+ mL blood loss 1.
• Check for signs of ongoing bleeding: expanding hematoma size, increasing pain, or deteriorating hemodynamics 1.
• If the patient is conscious, talking, and has a palpable peripheral pulse, blood pressure is likely adequate and aggressive resuscitation may not be immediately necessary 1.

Laboratory Investigations

• Obtain baseline complete blood count (FBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), and Clauss fibrinogen 1.
• Type and cross-match blood in case transfusion becomes necessary 1.
• Monitor serial hemoglobin and hematocrit to assess for ongoing blood loss 1.

Imaging

• The ultrasound has already confirmed the diagnosis, showing a complex fluid collection with echogenic material consistent with clot 2.
• Consider CT scan if there is concern for active bleeding, vascular injury, or if the clinical picture is unclear 1.

Conservative Management Strategy

Primary Approach

• Most groin hematomas resolve spontaneously with conservative management 2, 3.
• Apply local pressure if there is evidence of continued oozing from puncture sites 1.
• Bed rest initially to minimize movement and prevent hematoma expansion 3.
• Active warming of the patient if hypothermic 1.

Pain Management

• Provide adequate analgesia while avoiding NSAIDs that could worsen bleeding 1.
• Monitor pain intensity as increasing pain may indicate expanding hematoma 2.

Monitoring Protocol

• Serial clinical assessments looking for hematoma expansion, skin changes, or neurovascular compromise 1.
• Check for femoral nerve palsy (hip flexion weakness, knee extension weakness, sensory loss over anterior thigh) as groin hematomas can cause femoral neuropathy 2.
• Monitor for signs of compartment syndrome: severe pain, paresthesias, pallor, pulselessness 2.

Coagulation Management

Anticoagulation Considerations

• If the patient is on anticoagulation, assess whether reversal is necessary based on bleeding severity and coagulation parameters 2.
• For patients with INR >1.8, consider reversal agents if bleeding is ongoing 1.
• Coagulopathy should be anticipated and corrected aggressively if present 1.

Blood Product Support

• Transfuse packed red cells if hemoglobin drops significantly or patient becomes hemodynamically unstable 1.
• Fresh frozen plasma (FFP) if PT/aPTT >1.8 times normal 1.
• **Fibrinogen replacement if level <1.0 g/L** (target >1.5 g/L in active bleeding) 1.
• Platelet transfusion if count <80 × 10⁹/L in the setting of ongoing bleeding 1.

Indications for Surgical Intervention

When to Consider Surgery

• Hemodynamic instability despite resuscitation 1.
• Expanding hematoma with ongoing active bleeding 1.
• Neurovascular compromise (femoral nerve palsy, vascular occlusion) 2, 4.
• Compartment syndrome requiring decompression 2.

Surgical Approach

• Surgery should be considered early if conservative measures fail, but may need to be limited to "damage control" initially 1.
• Surgical excision is definitive treatment for organized hematomas causing mass effect 4.

Post-Acute Management

Follow-up Care

• Admit to monitored setting for observation of coagulation parameters, hemoglobin, and clinical status 1.
• Serial ultrasound examinations to document hematoma resolution 3.
• Most hematomas resolve within 1-2 weeks, though larger collections may take longer 5.

Thromboprophylaxis

• Once bleeding is controlled, initiate venous thromboprophylaxis as soon as possible as patients rapidly develop a prothrombotic state 1.

Common Pitfalls

• Avoid aggressive fluid resuscitation with crystalloids alone in large hematomas; use blood products when indicated 1.
• Do not ignore subtle signs of femoral nerve compression (weakness of hip flexion or knee extension) 2.
• Avoid vasopressors until bleeding is controlled and volume status is optimized 1.
• Do not delay surgical consultation if the hematoma is expanding or causing neurovascular compromise 2, 4.