What is the best practice for managing a 10 cm hematoma in a patient?

Management of a 10 cm Hematoma

For a 10 cm hematoma, immediate assessment of hemodynamic stability, location, and associated symptoms is critical, with surgical evacuation strongly indicated for intracranial hematomas >3 cm causing mass effect, large muscular hematomas with compartment syndrome, or any hematoma causing hemodynamic instability. 1

Initial Assessment and Stabilization

The first priority is determining the hematoma location and the patient's hemodynamic status:

• Secure large-bore IV access (8-Fr central line preferred) and obtain baseline coagulation studies including PT, aPTT, Clauss fibrinogen, platelet count, and cross-match 2, 1
• Administer high-flow oxygen and apply direct pressure to any accessible bleeding points 2, 1
• Perform near-patient testing with TEG or ROTEM if available to rapidly assess coagulation status and guide hemostatic management 2, 1, 3
• Assess physiology rapidly: skin color, heart rate, blood pressure, capillary refill, and conscious level to identify those at risk of decompensation 2

Critical pitfall: Some patients compensate well despite significant blood loss initially, so do not rely solely on blood pressure—look for subtle signs of shock 2

Location-Specific Management

Intracranial Hematoma (10 cm)

Cerebellar location requires immediate surgical evacuation if the hematoma is >3 cm with brainstem compression or hydrocephalus 2. For a 10 cm cerebellar hematoma, this is an absolute indication for urgent craniotomy, as ventricular catheter alone is insufficient 2.

Supratentorial hematomas require different approaches:

• Temporal/temporoparietal hematomas >3 cm (especially >30 cc) carry high risk of transtentorial herniation and warrant urgent surgical intervention 4
• Lobar hematomas within 1 cm of cortical surface may benefit from surgical evacuation within 96 hours 2
• Deep subcortical hematomas generally have worse outcomes with surgery unless causing significant mass effect 2

Large Muscular/Soft Tissue Hematoma (10 cm)

Begin immediate hemostatic resuscitation with warmed blood products, not crystalloids alone, maintaining 1:1 ratio of RBCs to FFP until coagulation results available 1:

• Target fibrinogen >1.5 g/L and platelets >75 × 10⁹/L as levels below these thresholds increase bleeding risk 1
• Administer tranexamic acid within 3 hours: 1 g IV over 10 minutes, then 1 g IV over 8 hours 1
• Monitor for compartment syndrome with serial neurovascular examinations 1

Surgical evacuation is indicated when:

• Tissue pressure causes overlying skin necrosis or ischemia 5
• Compartment syndrome develops 1
• Progressive expansion despite hemostatic measures 5

Pelvic Hematoma with Ring Disruption

Immediate pelvic ring closure and stabilization is required for patients in hemorrhagic shock 2. If hemodynamic instability persists despite stabilization, proceed urgently to angiographic embolization or surgical packing 2.

Anticoagulation Reversal (If Applicable)

For patients on warfarin, administer PCC immediately 1:

• INR 2-3.9: 25 units/kg PCC 1
• INR 4-5.9: 35 units/kg PCC 1
• INR >6: 50 units/kg PCC 1

Imaging Strategy

Hemodynamically stable patients require CT imaging to characterize hematoma size, location, and mass effect 2. Hemodynamically unstable patients with identified bleeding source should proceed directly to bleeding control without delay for imaging 2.

FAST ultrasound should be performed immediately in trauma patients with suspected torso bleeding 2.

Ongoing Management

All patients with 10 cm hematomas require critical care admission for monitoring of 2, 1:

• Coagulation parameters (PT, aPTT, fibrinogen, platelets) every 4-6 hours initially
• Hemoglobin and blood gases
• Signs of rebleeding or compartment syndrome
• Neurological status (for intracranial hematomas)

Initiate venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 2, 1. Temporary IVC filtration may be necessary in high-risk cases 2.

Key Clinical Pitfalls

• Do not wait for "normal" blood pressure before intervening—restore organ perfusion but avoid vasopressors until bleeding is controlled 2
• Do not rely on single hematocrit measurements to assess bleeding severity 2
• Use serum lactate and base deficit to estimate and monitor extent of bleeding and shock 2
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 2
• Anticipate and aggressively treat coagulopathy—it evolves rapidly in massive hemorrhage 2