What is the appropriate management of a subgaleal hematoma in an 89‑year‑old patient?

Management of Subgaleal Hematoma in an 89-Year-Old Patient

Conservative management with compression bandaging is the recommended first-line approach for subgaleal hematoma in elderly patients, with close monitoring for hemodynamic instability and coagulopathy correction if the patient is anticoagulated.

Initial Assessment and Stabilization

Hemodynamic Evaluation

• Immediately assess vital signs with particular attention to heart rate >90 bpm and systolic blood pressure <110 mmHg, as elderly patients require lower thresholds for trauma protocol activation 1
• Obtain baseline complete blood count, coagulation profile (PT, INR, aPTT), and type-and-crossmatch to guide resuscitation decisions 2, 3
• Monitor for absolute hematocrit decrease >5-6%, which signals significant ongoing bleeding and warrants escalation of care 2
• Perform serial base deficit and lactate assessments as markers of occult hypoperfusion, as elderly patients may not manifest typical signs of shock 1

Imaging

• Obtain CT scan of the head to characterize hematoma size, rule out intracranial extension, and exclude skull fractures 4, 5
• The diagnostic yield of contrast-enhanced CT outweighs the risk of contrast-induced nephropathy in elderly trauma patients 1

Anticoagulation Reversal (If Applicable)

For Warfarin

• Administer 4-factor prothrombin complex concentrate (4F-PCC) immediately: 25 units/kg for INR 2-3.9,35 units/kg for INR 4-5.9, or 50 units/kg for INR >6 2, 3
• Give 5 mg intravenous vitamin K concurrently 2
• Target INR <1.5 before any invasive intervention 2
• Fresh frozen plasma should only be used if 4F-PCC is unavailable, as it is markedly less effective 2

For Direct Oral Anticoagulants (DOACs)

• Dabigatran: Administer idarucizumab 5 g IV immediately; if unavailable, use activated PCC 50 units/kg IV 2
• Rivaroxaban/Apixaban: Use andexanet alfa (dosing based on protocol) or 2,000 units of 4F-PCC if andexanet is unavailable 2, 5
• Measure DOAC plasma levels when possible before reversal to avoid unnecessary thromboembolic risk 2

Conservative Management Protocol

Primary Treatment Approach

• Apply compression bandaging with non-elastic bandage providing direct pressure to the hematoma 4
• Most subgaleal hematomas resolve spontaneously without need for aspiration or drainage 4, 5
• Hospitalize for close observation, particularly in anticoagulated patients or those with large hematomas 4, 5

Monitoring Parameters

• Serial hemoglobin/hematocrit measurements to detect ongoing bleeding 5
• Continuous assessment of hematoma size and extension 4, 5
• Watch for complications including periorbital extension, signs of infection, or airway compromise 5
• Monitor for signs of rebleeding or expansion, particularly in the first 12-36 hours 3

Surgical Intervention Indications

When to Escalate

• Needle aspiration followed by compression dressing may be attempted if hematoma volume continues to increase despite conservative measures 6, 7
• Endovascular treatment with selective coil embolization of feeding vessels is a novel option for refractory cases that fail conservative management 6
• Surgical incision and drainage is reserved for cases where non-invasive management fails or severe complications develop 4

Critical Pitfalls to Avoid

• Do not delay anticoagulation reversal while awaiting laboratory results in hemodynamically unstable patients; immediate reversal based on clinical presentation is essential 2
• Do not use vasopressors for hemorrhagic hypotension, as the underlying problem is hypovolemic shock requiring volume resuscitation 2
• Avoid prolonged compression bandaging as extended use can cause scalp tissue necrosis requiring debridement and reconstruction 7
• Do not underestimate bleeding risk in elderly patients, as postoperative mortality increases significantly with age (9.8% in patients aged 80-89 years) 1
• Monitor for coagulopathy development as patients with massive hemorrhage rapidly develop prothrombotic states after initial bleeding control 3

Special Considerations for Elderly Patients

• Assess frailty using validated tools to predict in-hospital mortality and identify patients at highest risk of poor outcomes 1
• Consider comorbidities and medication history that may complicate resuscitation and coagulation management 1
• Initiate venous thromboprophylaxis as soon as bleeding is controlled, as elderly patients rapidly develop prothrombotic states 3
• Maintain normothermia and actively warm all transfused fluids to prevent hypothermia-induced coagulopathy 3