What are the differences in management and prognosis between stable, expanding, and pulsatile hematomas in patients, including those on anticoagulants (anti-coagulation therapy)?

Differences Between Stable, Expanding, and Pulsatile Hematomas

The classification of hematomas as stable, expanding, or pulsatile fundamentally determines whether immediate surgical exploration is required versus conservative management, with pulsatile and expanding hematomas demanding urgent intervention while stable hematomas can be safely observed.

Clinical Definitions and Immediate Management Implications

Pulsatile Hematomas

• Pulsatile hematomas indicate active arterial injury and require immediate surgical exploration without delay 1
• These represent ongoing hemorrhage from a major arterial source with high risk of exsanguination 1
• No role exists for observation or imaging workup when pulsatility is present—direct operative intervention is mandatory 1

Expanding Hematomas

• Expanding hematomas signify ongoing bleeding and similarly mandate immediate surgical exploration 1
• The expansion indicates failure of hemostasis and progressive accumulation of blood 2
• In anticoagulated patients, expansion occurs more frequently—particularly with novel oral anticoagulants (NOACs) where hematoma expansion rates reach 35.9% in traumatic intracerebral hemorrhage 3
• NOAC-associated hematomas show significantly higher expansion rates compared to vitamin K antagonists (p=0.05) or patients with normal coagulation (p=0.002) 3

Stable, Non-Pulsatile Hematomas

• Stable, non-pulsatile, non-expanding hematomas can be managed conservatively with observation, even in the presence of other injuries 2
• These represent contained hemorrhage with achieved hemostasis 2
• Retroperitoneal hematomas meeting these criteria (stable, non-pulsatile, non-expanding) should be left undisturbed during laparotomy 2

Management Algorithm for Anticoagulated Patients

Initial Assessment

• All hematomas in anticoagulated patients require classification as major versus non-major bleeding 4
• Major bleeding is defined by: bleeding at critical sites (intracranial, retroperitoneal, intramuscular, intra-articular), hemodynamic instability, or hemoglobin drop ≥2 g/dL 4
• Intramuscular and intra-articular hematomas are considered critical site bleeds due to risk of compartment syndrome and irreversible joint damage 4

For Expanding or Pulsatile Hematomas in Anticoagulated Patients

Immediate actions:

• Stop all oral anticoagulants and antiplatelet agents immediately 4
• Administer reversal agents: andexanet alfa for apixaban/rivaroxaban, idarucizumab for dabigatran, or 4F-PCC with 5-10 mg IV vitamin K for warfarin 4, 5
• Provide hemodynamic support with volume resuscitation 4
• Proceed to surgical or procedural management only after controlling coagulopathy and stabilizing the patient 5

Reversal agent considerations:

• Andexanet alfa shows lower in-hospital mortality (6.0%) compared to 4F-PCC (10.6%) in retrospective analyses, though with numerically higher thromboembolic complications 4
• For intracranial hemorrhage specifically, mortality remains high (23%) regardless of reversal strategy 4

For Stable Hematomas in Anticoagulated Patients

Conservative management approach:

• Continue oral anticoagulation if the hematoma is truly stable and non-expanding 4
• Provide local therapy/manual compression as applicable 4
• Consider 2-5 mg oral or IV vitamin K if on warfarin for non-major bleeding 4
• Assess for compartment syndrome even in painless presentations, particularly for intramuscular hematomas 5

Monitoring requirements:

• Ultrasound characterization to determine size, extent, presence of liquefaction, vascular involvement, or pseudoaneurysm formation 5
• Serial hemoglobin/hematocrit measurements to detect occult ongoing blood loss 5
• Apixaban's half-life extends to 17 hours in elderly patients and those with renal impairment, prolonging bleeding risk 5

Diagnostic Approach for Proximity Injuries

• Contrast arteriography should be used selectively for injuries in proximity to major vessels without hard signs (pulsatile hemorrhage, expanding hematoma, absent pulses) 1
• This approach reduces negative exploration rates from 84% to 2.4% compared to routine exploration 1
• Patients with hard signs (pulsatile or expanding hematomas) require immediate exploration without arteriography 1

Critical Pitfalls to Avoid

Anticoagulation-Specific Concerns

• Do not assume vitamin K antagonist-associated hematomas behave similarly to NOAC-associated hematomas—NOACs show higher expansion rates 3
• Hematoma volume in anticoagulated patients is significantly larger than in non-anticoagulated patients, though mortality differences are not statistically significant once hemorrhage occurs 6
• Consider prophylactic reversal of NOACs at admission for traumatic intracerebral hematomas given the high expansion rate 3

Surgical Decision-Making Errors

• Never explore stable, non-pulsatile, non-expanding retroperitoneal hematomas during laparotomy—this risks converting contained hemorrhage into uncontrolled bleeding 2
• Do not delay surgical intervention for pulsatile or expanding hematomas to obtain imaging or laboratory studies 1
• Hemodynamic instability is defined as systolic BP <90 mmHg, mean arterial pressure <65 mmHg, or orthostatic changes (systolic drop ≥20 mmHg or diastolic drop ≥10 mmHg) 4

Restarting Anticoagulation

• Delay restarting anticoagulation if bleeding occurred at a critical site, high rebleeding risk exists, source not definitively treated, or procedures are planned 5, 7
• Restart within 7 days if high thrombotic risk (CHA₂DS₂-VASc ≥2, recent VTE) and bleeding controlled 5
• Anticoagulation should only be discontinued permanently for critical bleeding or high risk of rebleeding with death/disability 7