WHEN DOES A HEMATOMA NEED TO BE DRAINED?

Overview

A hematoma refers to a pooling of blood in the surrounding tissues after an injury to the blood vessels. An injury to small blood vessels is called a bruise, whereas if larger blood vessels are involved, it is termed a hematoma. A hematoma is generally associated with pain and swelling. Injuries occurring in capillaries, veins, or arteries can form hematomas.

The difference between a hematoma and a hemorrhage is that the latter refers to persistent bleeding, whereas the former typically has already formed a clot. A hematoma can arise from injuries, certain medications such as aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran, and bleeding disorders such as thrombocytopenia.

Most hematomas are harmless and not a cause for concern. They usually resolve over time as the blood clot is removed and the blood vessels are repaired. However, some hematomas need surgical drainage depending on the location and symptoms.

Types of hematoma

Hematomas are classified and named based on their location in the body. The severity and need for surgical drainage are also primarily based on the location of the hematoma. A few examples of hematomas include:

• Epidural hematoma: A collection of blood between the skull and the dura mater (the outer protective lining of the brain).
• Subdural hematoma: It is the collection of blood between the dura mater and the arachnoid mater (lining of the brain that lies deeper than the dura mater).
• Muscular hematoma: It is a hematoma formed within the muscle group
• Ear hematoma: It occurs between the auricular cartilage and the perichondrium.
• Peritoneal hematoma: Hematoma formed within the peritoneum.
• Retroperitoneal hematoma: Hematoma formed in the retroperitoneal structures, posterior to the peritoneum.
• Intraabdominal hematoma: Hematoma formed within the abdomen.
• Splenic hematoma: It is a hematoma formed in the spleen.
• Hepatic hematoma: Hepatic hematomas are formed in the liver.
• Scalp hematoma: Hematoma formed within a layer of the scalp.
• Nasal septal hematoma: A septal hematoma is formed within the nasal septum, separating two nasal passages.

Treatment for Hematoma

The treatment of hematoma depends on the location, symptoms, and medical condition of the patient. Most hematomas require no specific treatment and resolve on their own. However, sometimes they can be a medical emergency requiring prompt treatment.

Even if the hematoma resolves on its own, self-care is important to prevent complications and reduce pain and swelling.

The following steps can be carried out to care for hematoma at home. These steps can be remembered with the acronym RICE.

• Rest.
• Ice: apply an ice pack or compression for 20 minutes at a time for 48 hours following the injury to reduce swelling and inflammation.
• Compression: Light compression is helpful by wrapping the area with an elastic bandage.
• Elevation: Elevation of the injured area above the level of the heart is recommended.
• Additionally, you can take pain medications such as acetaminophen. However, do not consume other pain medications like aspirin or ibuprofen on your own, as they can slow the clotting process and increase the risk of bleeding.

Surgical Drainage

In certain situations, hematomas require surgical drainage. It depends on the location of the hematoma and the severity of the symptoms. It also dictates the type of procedure and its urgency.

Certain indications for surgical drainage of hematoma are mentioned below:

1. Epidural Hematoma: This type of hematoma is generally due to arterial bleeding between the skull plate and the outer lining of the brain. The cause of epidural hematoma is almost always traumatic.

Urgent surgical hematoma evacuation is required for the patient with large extradural hematoma, i.e., >30 ml or causing a focal or progressive neurological deficit. This is particularly important to prevent brain death caused by increased pressure inside the brain. The evacuation of the hematoma is done by a neurosurgeon.

Other indications for surgical evacuation include cases of coma or showing early signs of brain herniation in imaging.

Other patients with smaller epidural hematomas can be managed conservatively by close observation and by preventing complications.

2. Subdural hematoma: Subdural hematoma is generally the tearing of veins in the space between the internal linings of the brain. It is a neurological emergency that may cause irreversible brain damage and death. So, they must be evaluated for surgical drainage immediately. A clinical examination and brain imaging are required for assessment.

Most subdural hematomas can be managed conservatively. A study done in 2015 on people with subdural hematomas showed that the majority received conservative treatment. Only 6.5% of these study participants required surgical drainage later in life.

The following are the clinical indications for surgical drainage of subdural hematoma:

• Subdural hematoma with >10 mm of maximal thickness in imaging
• Imaging shows brainstem compression or >5mm of midline shift
• Hematoma causing drowsiness or dilated pupils
• The patient continues to deteriorate clinically

Patients who do not fulfil the above criteria for surgical drainage should be monitored regularly for at least 24 hours. The surgical drainage is done by a neurosurgeon.

3. Muscle hematoma: Muscle hematoma is due to the extravasation of blood in the muscle group. They can be spontaneous or traumatic. Generally, traumatic hematomas are managed conservatively and resolve on their own. However, there is a risk of ongoing bleeding in spontaneous hematoma that can be life-threatening. So, the bleeding vessel must be identified using a CT angiogram.

Surgical evacuation of muscular hematoma is indicated when there is a neurological compromise due to the hematoma or localized ischemia. Surgical evacuation is usually performed by a general surgeon or an orthopedic or trauma surgeon. Arterial embolization is also considered a treatment option for muscular hematoma.

4. Auricular hematoma: Auricular hematoma forms in the auricle due to direct trauma. Every auricular hematoma must be drained. If not drained, it can disrupt the blood supply to the auricular cartilage, causing necrosis.

In patients with hematomas less than 2 cms in diameter and presenting within 48 hours, needle aspiration is suggested.

Incision and drainage are suggested for larger hematomas more than 2 cms in diameter or those presenting after 48 hours. The evacuation for auricular hematoma is done by an ENT surgeon

5. Subungal hematoma: It is a hematoma under a fingernail or toenail. Trephination is the process of placing one or more holes in the nail to permit the drainage of blood. It is indicated if the hematoma is acute, not spontaneously draining, with intact nail folds, and painful. The procedure is not effective after 48 hours. Trephination can be done by electrocautery, laser, syringe, or nail puncture.

6. Lower limb hematoma: A hematoma on the shin is usually treated by surgical drainage. Other hematomas on the lower leg are mostly treated conservatively. Similarly, a large hematoma that does not improve over a week usually requires surgical drainage.

Complications

If a hematoma is left untreated, it can sometimes result in various complications. Complications also vary according to the site.

• Hematoma in the brain can permanently damage brain cells leading to loss of brain function in the part involved.
• Auricular hematoma, if untreated, can lead to the death of auricular cartilage.
• Nasal septal hematoma has a high risk of forming an abscess and can lead to sepsis.
• Muscle hematoma can undergo a reactive process resulting in myositis ossificans, in which muscle loses its function and elasticity.

Final Takeaway

Hematoma is the accumulation of blood in the surrounding tissues following an injury to blood vessels. Most hematomas resolve on their own. However, adequate care is required to avoid complications.

The requirement for surgical drainage of hematoma varies according to the location and severity of the hematoma. Those who have head injuries, ear injuries, or show signs of infection such as discoloration, swelling, and a localized rise in temperature, should seek urgent medical care. If the condition is identified in time and with appropriate intervention, complications are unlikely.

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References:

• Johnson, D., Kohi, M., Fidelman, N., Taylor, A. G., Kolli, K., LaBerge, J., & Kerlan Jr, R. K. (2013). Hematomas-to drain or not to drain, the interventionalist's dilemma. Journal of Vascular and Interventional Radiology, 24(4), S57.
• Davis, D. D., & Kane, S. M. (2021). Muscular Hematoma. In StatPearls [Internet]. StatPearls Publishing.
• Hui, S. H., & Lui, T. H. (2016). Subperiosteal hematoma of the ankle. Journal of Orthopaedic Case Reports, 6(1), 63.
• Jamieson, K. G., & Yelland, J. D. N. (1968). Extradural hematoma: report of 167 cases. Journal of neurosurgery, 29(1), 13-23.
• Ducruet, A. F., Grobelny, B. T., Zacharia, B. E., Hickman, Z. L., DeRosa, P. L., Anderson, K., ... & Connolly, E. S. (2012). The surgical management of chronic subdural hematoma. Neurosurgical review, 35(2), 155-169.
• Brickman, K., Adams, D. Z., Akpunonu, P., Adams, S. S., Zohn, S. F., & Guinness, M. (2013). Acute management of auricular hematoma: a novel approach and retrospective review. Clinical Journal of Sport Medicine, 23(4), 321-323.
• Cohen, P. R., Schulze, K. E., & Nelson, B. R. (2007). Subungual hematoma. Dermatology Nursing, 19(1).

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