How should I urgently evaluate and manage an uninsured adult male with a large, rapidly expanding left hip/leg hematoma three weeks after a fall, suspected femoral artery injury, no anticoagulant use, and financial concerns?

Immediate Emergency Department Transfer Required for Suspected Vascular Injury

This patient requires immediate emergency department transfer regardless of insurance status—a large, rapidly expanding hematoma three weeks post-trauma with significant pain and functional impairment suggests active bleeding or pseudoaneurysm formation that can be life-threatening. 1, 2

Critical Red Flags Present in This Case

Your patient demonstrates multiple high-risk features that mandate urgent vascular imaging and potential intervention:

• Expanding hematoma over 3 days ("hard as rock," causing waist to increase 4 sizes) indicates ongoing bleeding or pseudoaneurysm formation 1, 2
• Significant pain despite high pain tolerance suggests vascular injury with compartment pressure or nerve compression 1, 3
• Three-week delay allows pseudoaneurysms to enlarge and increases rupture risk—deep femoral artery pseudoaneurysms have a 33% rupture rate 3
• Hematoma extending across hip/abdomen/leg/back raises concern for retroperitoneal extension, which can be rapidly fatal 4

Immediate Actions Required in the Emergency Department

Diagnostic Imaging (First Priority)

• Obtain duplex ultrasound immediately upon ED arrival—physical examination alone misses more than 60% of pseudoaneurysms and cannot reliably distinguish expanding hematoma from active arterial injury 1, 2
• CT angiography of pelvis and lower extremity if ultrasound confirms vascular injury or if retroperitoneal extension is suspected 4, 5
• The characteristic "to-and-fro" Doppler pattern on ultrasound confirms pseudoaneurysm 2, 6

Initial Stabilization

• Establish large-bore IV access (ideally 18-gauge or larger) immediately 4
• Obtain baseline laboratory studies: complete blood count, PT/aPTT, fibrinogen, type and cross-match for potential transfusion 4
• Monitor vital signs continuously for hemodynamic instability—patients can compensate well despite significant blood loss until sudden decompensation 4
• Assess distal perfusion: place pulse oximetry on the affected foot to detect arterial compromise 1

Management Algorithm Based on Imaging Findings

If Pseudoaneurysm Confirmed

For any symptomatic pseudoaneurysm (pain, expanding mass, compressive symptoms):

• Immediate intervention required regardless of size 2, 3
• Ultrasound-guided thrombin injection is first-line therapy, achieving 93% success rate even in large lesions 1, 2
• Surgical repair indicated if thrombin injection fails, rupture occurs, skin erosion present, or venous thrombosis/painful neuropathy develops 1, 2, 3

Deep femoral artery involvement (profunda femoris):

• Higher rupture risk (33%) demands more aggressive approach 3
• Endovascular coil embolization preferred for profunda pseudoaneurysms 3

If Active Hemorrhage or Massive Hematoma Without Pseudoaneurysm

• Surgical evacuation and hemostasis required for tense hematomas causing compressive symptoms or expanding despite conservative measures 1, 7
• Damage control surgery may be necessary if patient becomes hemodynamically unstable 4
• Transfusion threshold: maintain hemoglobin >8 g/dL in symptomatic patients with active bleeding 4

If Retroperitoneal Extension Suspected

• Immediate surgical consultation—retroperitoneal hemorrhage from femoral artery injury can be concealed and rapidly fatal 4, 1
• Aggressive resuscitation with blood products rather than crystalloid 4

Common Pitfalls to Avoid

Do not delay transfer based on insurance concerns—this is a potentially life-threatening vascular emergency that requires immediate imaging and intervention 1, 2. Most hospitals have financial assistance programs and cannot refuse emergency care.

Do not rely on clinical examination alone—the "hard as rock" quality and expansion pattern cannot distinguish between simple hematoma, pseudoaneurysm, or active bleeding without imaging 1, 2, 6.

Do not assume stability means safety—patients with massive hemorrhage can maintain adequate blood pressure through compensation until sudden cardiovascular collapse 4. The three-week delay with recent rapid expansion suggests either pseudoaneurysm formation or delayed rupture of an arterial injury.

Do not attempt outpatient management—even small (<2 cm) asymptomatic pseudoaneurysms require strict bed rest and serial ultrasound monitoring 2, 6, 8. Your patient's large, symptomatic, expanding lesion requires inpatient intervention.

Addressing Financial Concerns

• Emergency Medical Treatment and Labor Act (EMTLA) requires stabilization regardless of insurance status
• Arrange social work consultation in ED for financial assistance programs, charity care applications, and Medicaid emergency coverage
• Document medical necessity clearly—expanding hematoma with vascular injury concern constitutes an emergency that cannot be safely managed outpatient

Post-Intervention Monitoring

Once bleeding is controlled or pseudoaneurysm treated:

• Repeat duplex ultrasound at 24 hours to confirm successful treatment 2
• Mandatory follow-up ultrasound at 1 month to verify persistent thrombosis 1, 2
• Venous thromboprophylaxis should begin once hemostasis is secured, as trauma patients rapidly develop prothrombotic state 4