What is the appropriate management for a patient presenting with a hematoma under a wound, considering potential underlying bleeding disorders or anticoagulant use?

Management of Hematoma Under a Wound

For a hematoma under a wound, immediate evacuation is indicated if there are signs of skin necrosis, increased tissue pressure, or expanding hematoma, as delayed intervention leads to tissue ischemia and wound complications. 1

Initial Assessment and Stabilization

Evaluate the patient's hemodynamic status first to determine if this represents active bleeding requiring urgent intervention versus a contained hematoma:

• Assess vital signs and shock index (heart rate/systolic BP ratio): A shock index ≥0.9-1.0 indicates significant blood loss requiring immediate intervention 2
• Look for signs of ongoing bleeding: expanding hematoma, hemodynamic instability, or signs of hemorrhagic shock 2
• Examine for skin changes: skin necrosis, increased tension, or tissue compromise over the hematoma indicates urgent need for evacuation 3, 1
• Control any obvious external bleeding immediately with direct pressure, which remains the most effective initial intervention 4

Hemodynamic Management

If the patient shows signs of shock or active bleeding:

• Secure large-bore IV access (ideally 8-Fr central access in adults) 5
• Target systolic BP 80-100 mmHg until bleeding is controlled (avoid aggressive fluid resuscitation that may worsen bleeding) 5, 6
• Initially use crystalloids for resuscitation, adding blood products if massive hemorrhage is present 5
• Obtain baseline labs: CBC, PT, aPTT, fibrinogen, lactate, and base deficit to assess coagulopathy and shock severity 5, 6

Anticoagulant and Bleeding Disorder Considerations

Check coagulation status immediately in all patients:

• PT/aPTT >1.5 times normal or fibrinogen <1 g/L represents established coagulopathy requiring correction 2
• Administer FFP 15 ml/kg early if massive hemorrhage is anticipated to prevent coagulopathy 2
• Consider tranexamic acid 10-15 mg/kg IV followed by infusion of 1-5 mg/kg/h if significant bleeding is present 6, 7
• Reverse anticoagulation as appropriate based on the specific agent and clinical urgency 2

Source Control and Hematoma Management

The decision to evacuate depends on clinical presentation:

Immediate Evacuation Indicated:

• Skin necrosis or impending necrosis from tissue pressure 3, 1
• Expanding hematoma with hemodynamic compromise 2
• Signs of compartment syndrome or neurovascular compromise 1
• Large hematomas causing tissue ischemia even without increased pressure (due to cellular and biochemical changes) 1

Evacuation Technique:

• Can be performed under local anesthesia in the wound clinic setting for accessible hematomas 1
• Copious irrigation is essential after evacuation to remove blood clots and debris 8, 9
• Thorough debridement of any necrotic tissue under irrigation is critical 8, 9
• Consider delayed primary closure rather than immediate closure if contamination or tissue viability is questionable 8, 9

Conservative Management:

• Small, stable hematomas without skin compromise may be observed 1
• Apply light pressure dressing to minimize further swelling (avoid circumferential compression that could worsen ischemia) 4, 9
• Elevate and immobilize the affected area as adjunctive measures 4

Wound Management After Hematoma Evacuation

Follow surgical wound management principles:

• All necrotic tissue must be debrided as it provides medium for bacterial growth 8
• Drainage is critical: use active drainage systems (more efficient than passive Penrose drains) if significant fluid accumulation is expected 9
• Cover exposed drains with sterile absorbent dressing 9
• Consider delayed closure or healing by secondary intention if tissue viability is uncertain—premature closure leads to dehiscence and infection 9
• Split skin grafting may be required for large areas of skin loss 3

Ongoing Management

• Provide adequate analgesia: pain causes immunocompromise and impaired wound healing 9
• Monitor for infection: wound fluids and hematoma increase infection risk 9
• Daily dressing changes with local irrigation and debridement as needed if healing by secondary intention 9
• Begin venous thromboprophylaxis as soon as hemostasis is secured (patients develop prothrombotic state after hemorrhage) 2, 5

Critical Pitfalls to Avoid

• Do not delay evacuation when skin necrosis is present or imminent—tissue loss will progress 3, 1
• Avoid premature wound closure: if uncertain about tissue viability, use dressings and delayed closure 8, 9
• Do not apply circumferential compressive bandages that are too tight, as they may worsen ischemia 4
• Do not rely on single hemoglobin measurements to assess bleeding severity 5, 6
• Avoid incomplete debridement: this is the most common cause of wound infection and delayed healing 8, 9