What is the most likely diagnosis for a 70-year-old female with a history of hypertension (High Blood Pressure), hyperlipidemia (Elevated Lipid Levels), Chronic Obstructive Pulmonary Disease (COPD), fungal lung infection, hypothyroidism (Underactive Thyroid), Irritable Bowel Syndrome (IBS), left carotid arterial dissection, and history of Cerebrovascular Accident (CVA), presenting with ecchymosis, tenderness, and a palpable lump on the left calf following trauma?

From the Guidelines

For this 70-year-old female with a traumatic hematoma of the left calf, I strongly recommend proceeding with a lower extremity venous ultrasound to rule out deep vein thrombosis (DVT) given her significant vascular risk factors, including history of CVA and carotid arterial dissection, as supported by the principles outlined in the diagnosis of deep vein thrombosis 1.

Given her complex medical history, including hypertension, hyperlipidemia, COPD, fungal lung infection, hypothyroidism, IBS, left carotid arterial dissection, and history of CVA, it is crucial to manage her condition carefully to prevent further complications. The presence of ecchymosis, tenderness, and a palpable lump following trauma are classic signs of a traumatic hematoma, but her vascular history necessitates a thorough evaluation for DVT.

Key considerations in her management include:

• Ruling out DVT with ultrasound, as the symptoms of DVT can sometimes be subtle and her risk factors increase the likelihood of this condition 1.
• Monitoring for compartment syndrome, given the potential for increased pressure within the muscle compartments of the leg.
• Reviewing her anticoagulation status carefully, considering her history of CVA and the need to balance the risk of thrombosis against the risk of bleeding.

The initial treatment should focus on the RICE protocol:

• Rest to avoid further injury to the affected area.
• Ice application for 20 minutes every 2-3 hours to reduce pain and inflammation.
• Compression with an elastic bandage to help reduce swelling.
• Elevation of the affected leg above heart level when possible to decrease swelling.

For pain management, acetaminophen 500-1000mg every 6 hours as needed is recommended, avoiding NSAIDs due to the potential bleeding risk associated with her vascular history. Her anticoagulation regimen should be continued as prescribed, with careful monitoring for any signs of bleeding or thrombosis.

Follow-up in 1-2 weeks is essential to ensure the appropriate resolution of the hematoma and to assess for any complications. Discharge instructions should include returning immediately if she experiences increasing pain, swelling, warmth, redness, numbness, tingling, or inability to move the leg, which could indicate compartment syndrome or DVT development. This approach addresses both the immediate traumatic injury and her complex vascular history, minimizing the risk of morbidity, mortality, and impact on quality of life.

From the Research

Diagnosis and Treatment

• The patient's symptoms, including ecchymosis, tenderness, and palpable lump following trauma, are classic signs of a traumatic hematoma of the left calf 2.
• Given her vascular history, it is essential to rule out DVT with ultrasound and monitor for compartment syndrome, as seen in cases where compartment syndrome can occur spontaneously and in any compartment of the body 3.
• The patient's anticoagulation status should be reviewed, considering her history of CVA, and treatment should include rest, ice, compression, elevation, and pain management.

Compartment Syndrome and Anticoagulation

• Compartment syndrome is a condition that can cause vascular compromise, leading to ischemia and possible necrosis, and can occur after a traumatic event or spontaneously 3.
• The management of anticoagulation agents in trauma patients is crucial, and clinicians must be aware of drug mechanisms, assays to determine drug activity, and appropriate reversal strategies for patients on anticoagulants 4.
• The use of duplex ultrasound screening can detect high rates of deep vein thromboses in critically ill trauma patients, and it is recommended to screen all critically ill trauma patients for DVT, regardless of injury pattern or pharmacologic prophylaxis 5.

Traumatic Coagulopathy

• Traumatic coagulopathy is a multifactorial condition that can occur after trauma, and disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype is the predominant and initiative pathogenesis of coagulopathy at the early stage of trauma 6.
• The treatment of DIC involves the surgical repair of the trauma, improvement of shock, and the rapid and sufficient replacement of platelet concentrate, fresh frozen plasma, and depleted coagulation factors, as well as the administration of an antifibrinolytic agent (tranexamic acid) to reduce the risk of death in bleeding trauma patients 6.