When to Drain a Hematoma
A hematoma should be evacuated only when there is increased tension on the skin, as needle aspiration should otherwise be avoided due to the risk of introducing infection. 1
Location-Specific Drainage Indications
Cardiovascular Implantable Device Pocket Hematomas
- Drain only if skin tension is present – this is the primary indication for evacuation 1
- Needle aspiration carries significant infection risk by introducing skin flora into the pocket and should be avoided in all other circumstances 1
- Prevention is superior to treatment: use meticulous cautery, antibiotic-soaked sponge packing for tamponade, topical thrombin in anticoagulated patients, and pressure dressings for 12-24 hours post-closure 1
- Avoid low-molecular-weight heparin in the immediate postoperative period as it predisposes to hematoma formation 1
Chronic Subdural Hematomas
- Primary chronic subdural hematomas should be drained via burr-hole evacuation with closed-system drainage to prevent early postoperative deterioration and reduce recurrence rates 2, 3
- For recurrent chronic subdural hematomas, postoperative drainage (either external subdural drain or subdural-peritoneal catheter) significantly reduces secondary recurrence: 11% with drainage versus 33% without (P=0.040) 4
- The drain should remain in place for 48 hours in most cases 3
- If brain expansion occurs after evacuation making subdural drain placement difficult, a subperiosteal drain is an acceptable alternative 3
Subarachnoid Hemorrhage with Intraparenchymal Extension
- Urgent evacuation should be considered for patients with decreased level of consciousness and large intraparenchymal hematoma extension at the time the aneurysm is secured 1
- This applies specifically to the hyperacute setting when the aneurysm can be simultaneously addressed 1
Intracerebral Hemorrhage
- Stereotactic evacuation with fibrinolytic therapy (tPA) may be considered for specific cases, though this remains investigational 1
- Minimally invasive approaches with tPA instillation have shown 70-85% clot reduction with lower mortality in pilot studies, but routine use awaits completion of randomized trials 1
Extremity Hematomas
- Prompt operative evacuation should be performed when there is evidence of increased tissue pressure or risk of overlying skin necrosis 5
- Accumulation of blood causes cellular and biochemical changes leading to tissue ischemia and necrosis even without overt compartment syndrome 5
- These can be evacuated under local anesthesia in appropriate wound clinic settings 5
Critical Pitfalls to Avoid
Never perform needle aspiration of device pocket hematomas unless skin tension mandates evacuation – the infection risk (with potential device loss and 14% mortality) far outweighs any benefit 1
Do not delay drainage of extremity hematomas showing signs of skin compromise, as tissue necrosis can occur rapidly from both pressure and ischemic changes 5
For chronic subdural hematomas, do not omit drain placement after burr-hole evacuation unless technically impossible due to brain expansion, as this increases recurrence risk threefold 4, 2