Hematomas present as hard, solid and painful lumps or swellings under the skin. The overlying skin is often bruised and discoloured with ecchymosis as a common presentation. Intracranial hematomas also have symptoms of severe headache, nausea and vomiting, double vision, seizures and unconsciousness. The clinical presentation of intramural hematoma (IMH) and aortic double-lumen dissection (AD) is often similar [7] so a difference needs to be made with the help of imaging studies. Rectus sheath hematomas present with abdominal pain along with a palpable lump.

• Falling

  They can be caused by motor vehicle accident, falls and assaults. They are more common with an older patient resulting from a fall. [braininjury.com]

  Prohibit falls: Be cautious, especially if you are elderly or disabled, of fall risks such as walking on wet floors, climbing ladders and getting in and out of the tub. [baptisthealth.com]

  Falls can cause hematomas in the legs, chest, or brain, and may, at times, result in significant illness or death. Therefore, measures to prevent falls in this population potentially lower the frequency of hematomas as well. [rxlist.com]

• Fever

  The chest drainage tube was removed on postoperative day 12 because of persistent air leakage, but fever appeared the same day. Computed tomography revealed a cavity with mixed air and fluid, so antibiotics were started on suspicion of abscess. [ncbi.nlm.nih.gov]

  Large ones may present with lower abdominal pain, dysuria, anemia and fever (if infected). It is an uncommon complication of cesarean section, due to bleeding and uterine dehiscence, usually at transverse lower uterine incision. [radiopaedia.org]

  You have a fever. You have trouble moving the body part that has the hematoma. Contact your healthcare provider if: You have questions or concerns about your condition or care. [drugs.com]

  If infection should develop in the wound, the signs and symptoms might be increasingly severe pain, a fever of 101 degrees or more, swelling with surrounding redness, and pus. [healthcentral.com]

  Hemorrhagic fever, which literally stands for bleeding fever, produces the tell tale bruising all over the body. Other illnesses such as cancer that leave a loved on confined to a bed can be causes for such instances of blood related problems. [healthguidance.org]

• Asymptomatic

  In 3-week follow-up, asymptomatic emerging mass was observed at the same site, and needed a revision endoscopic resection. On pathologic examination, a low-grade angiosarcoma was identified, not organizing hematoma. [ncbi.nlm.nih.gov]

  Small hematomas may be asymptomatic. Large ones may present with lower abdominal pain, dysuria, anemia and fever (if infected). [radiopaedia.org]

  A subdural hygroma may therefore also occur after head trauma; they are frequently asymptomatic. [emedicine.medscape.com]

• Surgical Procedure

  Blood test for a complete blood count A physical examination to check vitals - heart rate and blood pressure to rule out internal bleeding Treatment The various treatment options are Craniotomy which is a surgical procedure where a part of the skull is [apollohospitals.com]

  What is Incision and Drainage of Hematoma, Seroma, or Fluid Collection: Overview, Benefits, and Expected Results Definition & Overview Incision and drainage is a minor surgical procedure for removing fluid buildup from under the skin or infected sinus [docdoc.com.sg]

  As a rule, an elective surgical procedure should produce optimal aesthetic results while limiting and minimizing complications. [jamanetwork.com]

  Surgical Procedures A person with a subdural hematoma may require emergency surgery to reduce pressure in the brain. The surgeon may drill a small hole in the skull to drain blood and reduce this pressure. [baptisthealth.com]

• Hoarseness

  Hoarseness. Dilation of the ascending aorta or the aortic arch can affect the recurrent laryngeal nerve, which supplies the vocal cords. There resulting vocal cord paralysis can lead to hoarseness. Cough. [verywellhealth.com]

  Hematoma evacuation, isthmecto-my Follicular adenoma 68/F None None NA Immediately Neck swelling, hoarseness, dysphonia. Rapid progression of respiratory distress. [jsms.sch.ac.kr]

  Rarely, patients have experienced syncope, anterior spinal pain syndrome, hoarseness, or acute renal insufficiency or have been asymptomatic.7,9 Table. [ahajournals.org]

• Rhinorrhea

  According to a study by Canty et al, the most common symptoms noted in children were nasal obstruction (95%), pain (50%), rhinorrhea (25%), and fever (25%). [4] Symptoms usually appear within the first 24-72 hours. [emedicine.medscape.com]

  The most frequent symptom is nasal congestion and rhinorrhea because of the obstruction and secondary inflammatory process by the mass. [ajnr.org]

• Abdominal Mass

  Computed tomography with intravenously administered contrast agent showed a solid mass of 5 × 5 × 8 centimeter in the left middle abdominal quadrant. [ncbi.nlm.nih.gov]

  WHAT CAUSES AN ABDOMINAL MASS? Abdominal masses can be the result of a number of factors, including an injury, cyst, tumor, cancer, or disease. [slideshare.net]

  The Fothergill sign (mass in the abdominal wall that does not cross the midline and does not change with flexion of the rectus muscles is suggestive of a rectus sheath hematoma) is useful to determine if the abdominal mass is within the abdominal wall [statpearls.com]

  Below the arcuate line, the aponeuroses remain intact anteriorly, but only the weak transversalis fascia and peritoneum separate the muscle mass from the abdominal viscera posteriorly. [reference.medscape.com]

• Dysphagia

  High clinical suspicion is warranted in patients who present with acute dysphagia, odynophagia, and dysphonia. Prompt imaging and airway management are vital in managing patients with this condition. [ncbi.nlm.nih.gov]

  They commonly occurred in the anterior triangle of the neck, causing airway compromise or dysphagia. Spontaneous cervical epidural haematoma is a well-known neurosurgical emergency. [bmcpediatr.biomedcentral.com]

  Hematoma evacuation, bleeder suture ligation Lymphocytic thyroiditis Roh [3] (2006) 55/F ESRD None NA 5 hr Neck pain and swelling, dysphagia. [jsms.sch.ac.kr]

• Constipation

  The clinician should obtain a thorough medical history to determine the presence of any risk factors like surgery, coughing, constipation, asthma, bronchitis, anticoagulation therapy and use of oral anticoagulants and steroids. [statpearls.com]

• Thrombosis

  […] adminadministratitrationlow-dosecurrence of a massive hematomathe rectus sheath is reported in a woman with chronic obstructive pulmonary disease and acute respiratory failure who was receiving low doses of heparin for the prevention of deep venous thrombosis [jamanetwork.com]

  A nurse on the island thought it could be a thrombosis. Since then a smaller "bubble" has appeared beside the larger one. [daneurope.org]

  Deep vein thrombosis of the lower leg was identified and edoxaban, a so-called novel oral anticoagulant, was started on postoperative day 7. [ncbi.nlm.nih.gov]

  Two patients had thrombosis of the basilar artery in the remainder descendent, ascendent, transtentorial herniations and extracranial hemations of the cerebral tissue were involved. [medvik.cz]

  Enforced bed rest in elderly patients may lead to pneumonia, deep venous thrombosis, and aspiration. [americannursetoday.com]

• Osteoporosis

  […] with current pathological fracture M80.0 Age-related osteoporosis with current pathological fracture M80.00 Age-related osteoporosis with current pathological fracture, unspecified site M80.00XA …… initial encounter for fracture M80.00XD …… subsequent [icd10data.com]

  (Korean J Med 2017;92:124-141) 다운로드 (기관인증 필요) 초록보기 Osteoporosis is a common adverse event among patients on glucocorticoid therapy. [kiss.kstudy.com]

  She had bilateral deep venous thrombosis (DVT) in 1994, she has asthma, hypertension, osteoporosis and macular degeneration. She was on multiple inhalers, warfarin, lansoprazole and antihypertensives. [ncbi.nlm.nih.gov]

  […] absorption and harming the patient.9 The adverse effects of subcutaneously administering enoxaparin include haemorrhaging complications, severe haematomas of the abdominal wall, necrosis of the skin and subcutaneous tissue10 and, over the longer term, osteoporosis [elsevier.es]

• Radiculopathy

  […] of only 1 per million, 15 the exceedingly high morbidity of untreated SSEH warrants its inclusion in the differential diagnosis of presentations suggesting spinal cord involvement. 2 SSEH can present with features ranging from simple back pain with radiculopathy [nature.com]

• Vertigo

  […] bradycardia, and respiratory irregularity (Cushing's reflex) Contralateral focal symptoms/ hemiplegia Impaired mental status, seizures, coma Clinical signs of skull fracture (e.g., local hematoma, swelling, laceration) Battle's sign Otorrhagia Hearing loss, vertigo [amboss.com]

Work up includes a thorough physical and neurological examination and patient history, followed by some laboratory tests and imaging studies

Laboratory tests

• Complete blood count
• Prothrombin time and APTT
• Liver function tests
• Serum BUN and electrolytes
• GCS measurement
• Serum alcohol levels

Imaging 

CT scans and MRI are the primary investigative and diagnostic tests for hematomas. Pre-contrast CT scans of an organized hematoma show hyperdense masses with or without calcification [8]. Doppler ultrasounds may also be conducted if needed.

Test results

On the basis of a thorough clinical examination and imaging studies the exact location and the extent of the hematoma can be found out. Tests can also help in assessing the risk of rupture of the hematoma and appropriate treatment can be accordingly planned.

Treatment of a hematoma depends on the severity and extent of the hematoma. According to panel consensus statements, if progressive hemorrhage as shown by 2 successive CT or MRI scans along with haemodynamic instability, persistent pain and signs of impending rupture are present, immediate surgical treatment is recommended. If such conditions are absent, medical treatment is recommended [9].

According to the findings of a recent study chances of a good recovery are possible if an aggressive surgical approach is taken in particular cases like those of patients with extradural hematomas [10]. Treatment with medication includes the use of osmotic diuretics, anticonvulsants, analgesics and corticosteroids. In cases of intracranial hematomas, antacids may also be given to reduce the chances of gastric ulcers.

If not treated, intracranial hematomas pose a negative prognosis with very high rates of mortality. The prognosis depends on the size, shape and thickness of the hematoma and how much it is suppressing the underlying and neighbouring structures. Hematomas occurring in the limbs as a result of trauma or in the abdomen usually have a good prognosis. Some hematomas don’t even require treatment and spontaneously resolve.

Causes behind intracranial hematomas include blunt head trauma, clotting disorders, intracranial hypotension like after spinal epidural anaesthesia [1] and lumbar puncture. Some of them are even idiopathic. Underlying arteriovenous (AV) malformations were also identified in one study [2].

Other hematomas can occur due to different causes. Some anticoagulant drugs like heparin or warfarin can also disrupt normal coagulation and cause hematomas. A study reported a case of sublingual hematoma secondary to warfarin therapy [3]. Trauma, AV malformations and clotting disorders are also various other kinds of hematoma formation.

Incidence

Hematomas are common findings in accidents and trauma cases. Around 5% to 25% of people with head trauma develop subdural hematomas and 2% develop epidural hematomas.

Sex

Subdural hematomas are more common in men, with a ratio of 3:1. Epidural hematomas are also more common in men, with a ratio of 4:1.

Age

Hematomas in children are rare unless the child is suffering from inherited coagulation disorders or has suffered trauma. They are much more common in adults in the 5th and 6th decade of life.

Hematomas are localized accumulations of blood outside the blood vessels. Epidural hematomas most commonly involve the middle meningeal artery. They are due to blunt trauma that causes the dura mater to separate from the periosteum and the blood vessels in between to stretch and rupture. This leads to rapid leakage and flooding of blood between the meningeal layers. Subdural hematomas are also typically due to trauma. Some chronic subdural hematomas may enlarge from an osmotic gradient, drawing more fluid into the subdural space. The mechanism of calcification can also be the pathogenesis behind hematoma formation [4]. According to a study performed by Kawakami in 1989, it was found that the coagulation and fibrinolysis systems were both excessively activated due to unknown causes in cases of chronic subdural hematoma [5].

Rectus sheath hematoma (RSH) may develop due to rupture of epigastric arteries in the abdomen or the rectus muscle itself due to severe trauma [6]. Other less common types of hematoma include subungal hematoma which occurs under or around the nailbed, perianal hematoma, subgaleal hematoma which occurs between the periosteum and the galeal aponeurosis and subdermal hematoma which occurs under the skin and typically in muscles.

Hematomas can only be prevented by avoiding injuries and carefully monitoring the use of anticoagulant drugs.

Hematomas are localized collection of extravasated blood that leaks out of ruptured blood vessels and accumulates in the surrounding area. The hematoma may occur inside muscles, in internal organs, between two membranes, in joint cavities and under the skin. According to the area or site of the hematoma, it can be named and divided. By far, intracranial hematomas pose the greatest risk of rupture and damage, even death. Hematomas occurring under the skin of limbs and joints are less dangerous, but no less painful.

Definition

A hematoma is a collection of blood outside the blood vessels which appears as a hard lump or swelling.

Cause

It is most commonly a result of trauma. It may also occur due to clotting disorders, arteriovenous malformations, excessive alcoholism, anticoagulant therapy, etc.

Signs and symptoms

Symptoms include hard, solid swelling under the skin accompanied with pain. Intracranial hematomas also present with headache, double vision, nausea and vomiting, seizures and unconsciousness.

Diagnosis

Diagnosis is made be carefully assessing the physical findings and the results of imaging studies and laboratory tests.

Treatment

Treatment includes medication like painkillers, anticonvulsants, etc and in severe cases, surgical removal of the accumulated blood and repair of the ruptured blood vessels.

1. Mashour GA, Schwamm LH, Leffert L. Intracranial subdural hematomas and cerebral herniation after labor epidural with no evidence of dural puncture. Anesthesiology. Mar 2006;104(3):610-2
2. Sivakumaran R, King A, Bodi I, Chandler CL, Walsh DC. Spontaneous epidural spinal haematoma in children caused by vascular malformations. Eur Spine J. 2014 Oct 10 
3. Pathak R, Supplee S, Aryal MR, Karmacharya P. Warfarin induced sublingual hematoma: a Ludwig angina mimic. Am J Otolaryngol. 2014 Aug 20. pii: S0196-0709(14)00192-6. 
4. Atkinson JL, Lane JI, Aksamit AJ. MRI depiction of chronic intradural (subdural) hematoma in evolution. J Magn Reson Imaging. Apr 2003;17(4):484-6
5. Kawakami Y, Chikama M, Tamiya T, Shimamura Y. Coagulation and fibrinolysis in chronic subdural hematoma. Neurosurgery. Jul 1989;25(1):25-9
6. Sheth HS, Kumar R, DiNella J, Janov C, Kaldas H, Smith RE. Evaluation of Risk Factors for Rectus Sheath Hematoma. Clin Appl Thromb Hemost. 2014 Oct 7. 
7. Ibukuro K, Takeguchi T, Fukuda H, Mori M, Abe S, Tobe K. An analysis of initial and follow-up CT findings in intramural hematoma, aortic double-lumen dissection, and mixed type lesions. Acta Radiol. 2014 Sep 26. 
8. Chae HD, Choi SH, Park SH, Jung HW, Yun TJ, Kim JH, Sohn CH. Organized hematoma developed after suboccipital craniectomy. J Neuroimaging. 2014 Nov;24(6):610-2. 
9. Evangelista A, Czerny M, Nienaber C, Schepens M, Rousseau H, Cao P, Moral S, Fattori R. Interdisciplinary expert consensus on management of type B intramural haematoma and penetrating aortic ulcer. Eur J Cardiothorac Surg. 2014 Nov 10. 
10. Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J. 2014 Nov 10.