What is the appropriate management for a patient with a large contusion hematoma on the forehead?

Management of Large Forehead Contusion Hematoma

For a large contusion hematoma on the forehead, apply direct pressure with a non-elastic compression bandage as the primary treatment, with surgical drainage reserved only for cases with compressive complications, infection, or failure of conservative management.

Initial Assessment and Immediate Management

Control Active Bleeding

• Apply direct pressure immediately to any obvious bleeding sites, as this is of paramount importance in preventing expansion of the hematoma 1.
• Use compression dressings or bandages to achieve hemostasis 1.

Determine Hematoma Type and Extent

• A forehead contusion hematoma is most commonly subgaleal (beneath the galeal aponeurosis), which can accumulate significant blood volume due to the loose areolar tissue in this space 2.
• Assess for skull fracture, as 71% of patients with skull fractures have associated intracranial contusion or hematoma, compared to 46% without fractures 3.
• Obtain CT imaging if there is concern for underlying skull fracture or intracranial injury, particularly if the patient has altered consciousness, significant mechanism of injury, or neurological symptoms 2, 4.

Conservative Management (First-Line Treatment)

Compression Therapy

• Apply non-elastic bandage with direct compression as the primary treatment for subgaleal hematomas 2.
• Most hematomas are self-limited and resolve with conservative management 2.
• Continue compression for several days with close monitoring 2.

Monitoring Protocol

• Admit patients with large hematomas for observation, typically for up to one week 2.
• Monitor for expansion, signs of infection, or compressive complications 4.
• Watch for potential complications including airway compression (rare in forehead location), orbital compartment syndrome, or anemia requiring transfusion 4.

Indications for Surgical Intervention

When to Consider Drainage

Surgical drainage is indicated only when:

• Conservative management fails after appropriate trial of compression 2.
• Severe complications develop, including:
  • Infection of the hematoma 4
  • Compressive symptoms (orbital compartment syndrome in forehead hematomas) 4
  • Significant pain unrelieved by conservative measures 4
  • Anemia requiring transfusion 4

Surgical Approach

• If drainage is required, it can be performed under local anesthesia in most cases 2.
• A multidisciplinary approach with neurosurgery consultation is appropriate for severe cases 4.

Critical Pitfalls to Avoid

• Do not routinely drain forehead hematomas, as most resolve spontaneously with compression 2.
• Do not miss underlying skull fractures or intracranial injury - maintain a low threshold for CT imaging, especially given that 77% of patients with contusions have associated skull fractures 3.
• Do not ignore expanding hematomas - serial examinations are essential as delayed expansion can occur 2.
• In patients on antiplatelet or anticoagulant medications, be particularly vigilant for expansion and consider earlier imaging 5.

Post-Treatment Care

• Follow-up at 3 months to ensure complete resolution and no recurrence 2.
• Once bleeding is controlled and the patient is stable, initiate standard venous thromboprophylaxis as patients develop a prothrombotic state after hemorrhage control 1, 6.