What is the next step in managing a patient with a large hematoma in the right posterior calf and significant blood loss, possibly on anticoagulation therapy?

Management of Ruptured Calf Hematoma with Large Blood Loss

Immediately control bleeding with direct pressure, establish large-bore IV access (or intra-osseous if needed), administer high-flow oxygen, and prepare for urgent imaging to determine if surgical evacuation or arterial embolization is required. 1, 2

Immediate Stabilization Actions

Hemorrhage Control and Access

• Apply direct pressure to the bleeding site using compression dressings or tourniquets if external bleeding is visible 1, 2
• Establish large-bore IV access (ideally 8-Fr central line in adults) or consider intra-osseous access if peripheral access fails 1, 2
• Administer high-flow oxygen to maintain tissue perfusion 1, 2

Rapid Assessment

• Assess hemodynamic status: Check skin color, heart rate, blood pressure, capillary refill, and conscious level—if the patient is conscious and talking with a palpable peripheral pulse, blood pressure is adequate 1
• Look for signs of ongoing blood loss: Examine the wound site, clothing, floor, and assess for signs of compartment syndrome or expanding hematoma 1
• Obtain baseline labs immediately: Full blood count, PT, aPTT, Clauss fibrinogen (not derived), and cross-match 1

Resuscitation Strategy

Fluid Management

• Resuscitate with warmed blood and blood components, NOT crystalloids alone 1, 2
• Use blood group O initially (fastest availability), followed by group-specific, then cross-matched blood 1
• Maintain 1:1 ratio of FFP to red blood cells until coagulation results are available 2
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1

Coagulation Management

• Target fibrinogen >1.5 g/L (levels <1 g/L are insufficient in massive hemorrhage) 1
• Maintain platelet count >75 × 10⁹/L (levels <50 × 10⁹/L are strongly associated with microvascular bleeding) 1, 2
• Prevent dilutional coagulopathy with early FFP infusion 1

Anticoagulation Reversal (if applicable)

If the patient is on warfarin:

• Administer parenteral vitamin K1 (5-25 mg, rarely up to 50 mg) for major bleeding 3
• Give prothrombin complex concentrate (PCC) or fresh frozen plasma (200-500 mL) in severe hemorrhage to restore clotting factors 3
• For INR 2-3.9: 25 u/kg PCC; INR 4-5.9: 35 u/kg; INR >6: 50 u/kg 1

If on other anticoagulants (e.g., enoxaparin, rivaroxaban):

• Discontinue anticoagulation immediately 4, 5
• Consider specific reversal agents based on the anticoagulant used

Definitive Management

Imaging and Intervention

• Obtain urgent imaging (ultrasound, CT scan) to define hematoma size, location, and active bleeding 1, 6
• Consider radiologically-guided arterial embolization, which is highly effective and may eliminate the need for surgery 2, 5
• Surgical exploration and evacuation should be considered if:
  • Compartment syndrome is developing
  • Arterial embolization fails or is unavailable
  • Hematoma is causing significant tissue compromise 4, 7

Surgical Approach

• Evacuation can be performed via open surgery or endoscopic technique depending on chronicity and location 7
• "Damage control" surgery may be necessary—control bleeding first, then correct abnormal physiology 1

Post-Stabilization Care

Critical Care Monitoring

• Admit to critical care area for continuous monitoring 1, 2
• Monitor coagulation parameters, hemoglobin, and blood gases frequently 1, 2
• Aggressively normalize blood pressure, acid-base status, and temperature once bleeding is controlled (avoid vasopressors during active bleeding) 1, 2

Thromboprophylaxis

• Resume venous thromboprophylaxis as soon as bleeding is controlled—patients rapidly develop a prothrombotic state after massive hemorrhage 1, 2
• For patients with mechanical heart valves, temporary interruption of anticoagulation (1-2 weeks) appears safe without increased embolic risk 8
• Consider temporary inferior vena cava filtration if thromboprophylaxis cannot be safely resumed 1

Critical Pitfalls to Avoid

• Do not resuscitate with crystalloids alone—this worsens dilutional coagulopathy 1, 2
• Do not delay imaging—spontaneous calf hematomas can be mistaken for DVT, and management differs significantly 4
• Do not aim for normal blood pressure during active bleeding—restore organ perfusion but avoid aggressive BP normalization until bleeding is controlled 1
• Do not use derived fibrinogen levels—only Clauss fibrinogen is reliable in this setting 1