Overview

Hematomas represent a common medical condition that occurs when blood vessels rupture and blood collects in tissues, organs, or body spaces outside the vascular system. This pooling of blood creates a localized swelling that can range from minor and self-limiting to severe and life-threatening, depending on the location and size. While often confused with simple bruises (contusions), hematomas involve larger blood vessel damage and more significant blood accumulation, forming palpable or visible masses.

The body's response to vessel injury involves immediate vasoconstriction and activation of the clotting cascade to limit blood loss. However, when the vessel damage is significant or clotting is impaired, blood continues to leak into surrounding tissues, creating a hematoma. The collected blood initially appears as a firm, often painful swelling. Over time, the body breaks down and reabsorbs this blood through a process involving macrophages and the conversion of hemoglobin to bilirubin and hemosiderin, which accounts for the color changes seen in superficial hematomas.

The clinical significance of a hematoma depends largely on its location. Superficial hematomas in skin and muscle are usually benign and resolve with conservative treatment. However, hematomas in confined spaces like the skull, spine, or abdomen can cause dangerous pressure on vital structures. Understanding the various types of hematomas, their potential complications, and appropriate management strategies is crucial for healthcare providers and patients alike.

Symptoms

The symptoms of a hematoma vary significantly based on its location, size, and the rate of blood accumulation. While superficial hematomas are easily visible, deep hematomas may present with systemic symptoms.

Primary Symptoms

Location-Specific Symptoms

Superficial Hematomas:

  • Visible swelling or lump
  • Skin discoloration (purple, blue, green, yellow progression)
  • Tenderness or pain at the site
  • Warmth over the area
  • Firmness to palpation

Intracranial Hematomas:

  • Severe headache
  • Confusion or altered consciousness
  • Nausea and vomiting
  • Weakness or paralysis
  • Seizures
  • Unequal pupil size

Abdominal Hematomas:

  • Abdominal pain and tenderness
  • Abdominal distension
  • Signs of internal bleeding (pallor, tachycardia)
  • Nausea or vomiting
  • Referred pain to shoulder (splenic hematoma)

General Signs of Significant Hematoma

  • Increasing pain over time
  • Progressive swelling
  • Numbness or tingling (nerve compression)
  • Decreased range of motion
  • Signs of compartment syndrome
  • Systemic signs of blood loss

Types of Hematomas

Hematomas are classified based on their location in the body. Each type has unique characteristics and potential complications.

Intracranial Hematomas

Epidural Hematoma:

  • Between skull and dura mater
  • Often from arterial bleeding (middle meningeal artery)
  • Classic "lucid interval" presentation
  • Lens-shaped on CT scan
  • Surgical emergency

Subdural Hematoma:

  • Between dura and arachnoid mater
  • Venous bleeding from bridging veins
  • Acute, subacute, or chronic presentation
  • Crescent-shaped on CT scan
  • Common in elderly and alcoholics

Intracerebral Hematoma:

  • Within brain tissue
  • From trauma or spontaneous (hypertension, AVM)
  • Neurological deficits based on location
  • May require surgical evacuation

Soft Tissue Hematomas

Subcutaneous Hematoma:

  • Just beneath the skin
  • Visible bruising and swelling
  • Usually self-limiting
  • Common after injections or trauma

Intramuscular Hematoma:

  • Within muscle tissue
  • Can cause compartment syndrome
  • Common in athletes
  • May calcify if chronic (myositis ossificans)

Organ-Specific Hematomas

Splenic Hematoma:

  • Within or around spleen
  • Risk of delayed rupture
  • Left upper quadrant pain
  • Requires monitoring or surgery

Hepatic Hematoma:

  • In or around liver
  • Right upper quadrant pain
  • Can occur with HELLP syndrome
  • Risk of rupture into peritoneum

Retroperitoneal Hematoma:

  • Behind peritoneum
  • Often from trauma or anticoagulation
  • Can be massive before detection
  • Grey Turner's sign (flank bruising)

Special Types

Subungual Hematoma:

  • Under fingernail or toenail
  • Extremely painful due to pressure
  • May require nail trephination

Septal Hematoma:

  • In nasal septum
  • Can lead to septal necrosis
  • Requires prompt drainage

Auricular Hematoma:

  • In ear cartilage
  • "Cauliflower ear" if untreated
  • Common in contact sports

Causes

Hematomas result from blood vessel damage with subsequent bleeding into surrounding tissues. The causes range from trauma to spontaneous bleeding in susceptible individuals.

Traumatic Causes

  • Blunt trauma - Falls, motor vehicle accidents, sports injuries
  • Penetrating injuries - Stab wounds, gunshot wounds
  • Surgical procedures - Postoperative bleeding
  • Medical procedures - Injections, biopsies, catheterizations
  • Birth trauma - Cephalohematoma in newborns
  • Fractures - Associated soft tissue bleeding

Non-Traumatic Causes

  • Coagulation disorders - Hemophilia, von Willebrand disease
  • Thrombocytopenia - Low platelet count
  • Vascular malformations - AVM, aneurysms
  • Hypertension - Spontaneous intracerebral hemorrhage
  • Liver disease - Impaired clotting factor production
  • Vitamin deficiencies - Vitamin K, vitamin C (scurvy)

Medication-Related

  • Anticoagulants - Warfarin, heparin, DOACs
  • Antiplatelet agents - Aspirin, clopidogrel
  • Thrombolytics - tPA, streptokinase
  • Corticosteroids - Skin fragility, easy bruising
  • SSRIs - Increased bleeding risk

Pathophysiology

  • Vessel wall damage - Direct injury or weakening
  • Coagulation cascade failure - Inability to form stable clot
  • Increased vascular pressure - Hypertension, straining
  • Tissue factor exposure - Initiates clotting cascade
  • Inflammation - Increases vascular permeability

Risk Factors

Certain conditions and factors increase the likelihood of developing hematomas or experiencing complications from them.

Age-Related Factors

  • Elderly individuals - Fragile vessels, brain atrophy, fall risk
  • Infants - Birth trauma, non-accidental injury risk
  • Toddlers - Frequent falls during development

Medical Conditions

  • Bleeding disorders - Hemophilia A/B, von Willebrand disease
  • Platelet disorders - ITP, thrombocytopenia
  • Liver disease - Cirrhosis, hepatitis
  • Kidney disease - Uremic bleeding tendency
  • Cancer - Especially leukemia, liver cancer
  • Alcoholism - Falls, liver disease, brain atrophy

Lifestyle Factors

  • Contact sports - Boxing, football, martial arts
  • High-risk activities - Extreme sports, motorcycling
  • Occupational hazards - Construction, military
  • Substance abuse - Increased fall risk
  • Poor nutrition - Vitamin deficiencies

Iatrogenic Factors

  • Anticoagulation therapy - Especially with INR >3
  • Multiple medications - Drug interactions
  • Recent surgery - Postoperative bleeding
  • Frequent injections - Diabetes, anticoagulation
  • Dialysis - Heparin use, platelet dysfunction

Diagnosis

Diagnosis of hematomas involves clinical assessment and often imaging studies, particularly for deep or organ-specific hematomas.

Clinical Assessment

  • History - Trauma, medications, bleeding disorders
  • Physical examination - Location, size, consistency
  • Vital signs - Blood pressure, heart rate (blood loss)
  • Neurological exam - For head trauma
  • Serial examinations - Monitor progression

Laboratory Tests

  • Complete blood count - Hemoglobin, hematocrit, platelets
  • Coagulation studies - PT/INR, PTT, fibrinogen
  • Type and crossmatch - If transfusion needed
  • Liver function tests - If coagulopathy suspected
  • Specific factor assays - For bleeding disorders

Imaging Studies

Ultrasound:

  • First-line for superficial hematomas
  • Can measure size and monitor resolution
  • Doppler to assess vascular flow
  • Guided aspiration if needed

CT Scan:

  • Gold standard for intracranial hematomas
  • Excellent for acute bleeding
  • Can identify active extravasation
  • Useful for retroperitoneal hematomas

MRI:

  • Better for subacute/chronic hematomas
  • Excellent soft tissue detail
  • Can age hematomas by signal characteristics
  • Useful for spinal hematomas

Special Considerations

  • Compartment pressure measurement - If compartment syndrome suspected
  • Angiography - For vascular injuries
  • Diagnostic peritoneal lavage - Rarely used for abdominal bleeding

Treatment Options

Treatment of hematomas depends on location, size, symptoms, and underlying cause. Options range from conservative management to emergency surgery.

Conservative Management

RICE Protocol (for superficial hematomas):

  • Rest - Avoid activities that worsen injury
  • Ice - 20 minutes every 2-3 hours for first 48 hours
  • Compression - Elastic bandage to limit swelling
  • Elevation - Above heart level when possible

Additional Conservative Measures:

  • Pain management - Acetaminophen (avoid NSAIDs if bleeding risk)
  • Observation - Monitor for expansion
  • Activity modification - Gradual return to normal activities
  • Heat therapy - After 48-72 hours to promote reabsorption

Medical Management

  • Reversal of anticoagulation - Vitamin K, PCC, FFP
  • Platelet transfusion - For thrombocytopenia
  • Factor replacement - For hemophilia
  • Corticosteroids - For chronic subdural hematomas
  • Antifibrinolytics - Tranexamic acid in some cases

Interventional Procedures

Aspiration/Drainage:

  • Large, accessible fluid collections
  • Ultrasound or CT guidance
  • Serial aspirations may be needed
  • Risk of reaccumulation

Surgical Evacuation:

  • Indications:
    • Neurological deterioration
    • Mass effect
    • Compartment syndrome
    • Infected hematoma
    • Failed conservative management

Location-Specific Treatment

Intracranial Hematomas:

  • Epidural - Emergency craniotomy
  • Acute subdural - Craniotomy if >10mm or midline shift
  • Chronic subdural - Burr holes, observation if small
  • ICP monitoring - Guide management
  • Seizure prophylaxis - Anticonvulsants

Intramuscular Hematomas:

  • Compartment pressure monitoring
  • Fasciotomy if compartment syndrome
  • Physical therapy after acute phase
  • Gradual return to sports

Complications Management

  • Infection - Antibiotics, drainage
  • Calcification - Surgical excision if symptomatic
  • Chronic pain - Pain management, nerve blocks
  • Recurrence - Address underlying cause

Prevention

Preventing hematomas focuses on minimizing trauma risk and managing conditions that increase bleeding tendency.

General Prevention Strategies

  • Fall prevention - Remove hazards, improve lighting, use assistive devices
  • Protective equipment - Helmets, padding in sports
  • Safe driving practices - Seatbelts, avoid distracted driving
  • Home safety - Secure rugs, install grab bars
  • Workplace safety - Follow OSHA guidelines

Medical Management

  • Medication monitoring - Regular INR checks for warfarin
  • Appropriate dosing - Adjust anticoagulants based on risk
  • Drug interactions - Review all medications
  • Blood pressure control - Reduce spontaneous bleeding risk
  • Treat underlying disorders - Manage bleeding conditions

Lifestyle Modifications

  • Limit alcohol - Reduces fall risk and liver function
  • Adequate nutrition - Vitamins K and C
  • Exercise safely - Proper technique and equipment
  • Avoid high-risk activities - If on anticoagulation

Post-Procedure Care

  • Injection technique - Proper pressure after injections
  • Post-surgical monitoring - Watch for bleeding
  • Activity restrictions - Follow post-procedure guidelines
  • Compression therapy - After procedures when indicated

When to See a Doctor

While minor hematomas often resolve without treatment, certain situations require immediate medical attention.

Seek Emergency Care Immediately For:

  • Head injury with confusion, vomiting, or loss of consciousness
  • Severe headache after head trauma
  • Progressive neurological symptoms (weakness, numbness)
  • Signs of significant blood loss (dizziness, rapid pulse, pallor)
  • Severe abdominal pain after trauma
  • Difficulty breathing with chest wall hematoma
  • Loss of pulse below a limb hematoma

See a Doctor Within 24 Hours For:

  • Large hematomas (>5 cm diameter)
  • Hematomas that continue to expand
  • Severe pain not relieved by over-the-counter medication
  • Hematomas in high-risk locations (neck, genitals)
  • Multiple unexplained hematomas
  • Hematomas while on blood thinners

Schedule an Appointment If:

  • Hematoma doesn't improve after 2 weeks
  • Recurrent hematomas without clear cause
  • Signs of infection (warmth, red streaks, fever)
  • Persistent pain or limited range of motion
  • Concern about cosmetic appearance

Special Populations

  • Elderly - Lower threshold for evaluation
  • Children - Consider non-accidental injury
  • Pregnant women - Any abdominal trauma
  • Immunocompromised - Higher infection risk

Related Conditions

Several conditions are associated with or may be confused with hematomas:

References

  1. Frontera JA, et al. (2023). Management of Intracranial Hematomas. Neurocritical Care.
  2. Mehta A, et al. (2023). Soft Tissue Hematomas: Current Concepts in Management. Am J Sports Med.
  3. Bullock MR, et al. (2022). Surgical Management of Traumatic Brain Injury. Neurosurgery.
  4. American College of Emergency Physicians. (2023). Clinical Policy: Neuroimaging and Decision-Making in Adult Mild Traumatic Brain Injury.
  5. Stahel PF, et al. (2023). Current concepts of polytrauma management. European Journal of Trauma and Emergency Surgery.