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Hematoma

Hematomas are accumulations of extravasated blood that may occur in different sites of the body due to trauma or coagulation disorders.


Presentation

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.

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]
  • 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]
  • A fever. Watch closely for changes in your health, and be sure to contact your doctor or nurse call line if: The bruise lasts longer than 4 weeks. The bruise gets bigger or becomes more painful. You do not get better as expected.[myhealth.alberta.ca]
  • 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]
  • Twenty-four hours later she had a fever and a rise in leukocytes to 58 000 UL. With a diagnosis of shock of probable septic origin, an echocardiographic study was requested.[revespcardiol.org]
Abdominal Mass
  • CONCLUSION: On encountering an intra-abdominal mass found to be attached to a gastric wall, a gastric intramural hematoma should be considered. KEYWORDS: Gastric hematoma; Gastric intramural hematoma; Intra-abdominal aneurysm[ncbi.nlm.nih.gov]
Left Flank Pain
  • CASE PRESENTATION: A 60-year-old Japanese woman complained of left flank pain. 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]
Thrombosis
  • 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]
Jugular Venous Distention
  • He had jugular venous distention and Kussmaul's sign. Contrast-enhanced cardiac magnetic resonance imaging (CMRI) demonstrated an intrapericardial mass compressing the right ventricular (RV) cavity.[ncbi.nlm.nih.gov]
Grey Turner's Sign
  • Turner's sign ‎ (1 F) H Hematocele ‎ (1 C, 2 F) K Kidney hematoma ‎ (1 C) L Love-bite ‎ (5 F) N Nasal septal hematoma ‎ (1 F) P Perianal hematoma ‎ (2 F) R Rectus sheath hematomas ‎ (vuota) S Splenic hematoma ‎ (1 C) Subcutaneous hematomas ‎ (53 F) Subdural[commons.wikimedia.org]
  • Turner's sign ‎ (1 D) H Hematocele ‎ (1 K, 2 D) K Kidney hematoma ‎ (1 K) L Love-bite ‎ (5 D) N Nasal septal hematoma ‎ (1 D) P Perianal hematoma ‎ (2 D) R Rectus sheath hematomas ‎ (leer) S Splenic hematoma ‎ (1 K) Subcutaneous hematomas ‎ (53 D) Subdural[commons.wikimedia.org]
Dystonia
  • In this case report, we will discuss mimicking angioedema and caused by a bite due to dystonia and separation of the tongue from the base of the mouth developing concurrently with lingual hematoma.[ncbi.nlm.nih.gov]
Basal Ganglia Hemorrhage
  • OBJECTIVE: To investigate the clinical efficacy of navigation-guided minimally invasive surgery in patients with hypertensive basal ganglia hemorrhage.[ncbi.nlm.nih.gov]

Workup

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.

Staphylococcus Aureus
  • In contrast, neutrophil chemotaxis towards the FH was significantly inhibited by chemotaxis inhibitory protein of Staphylococcus aureus (CHIPS), which blocks FPR and C5aR.[ncbi.nlm.nih.gov]

Treatment

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.

Prognosis

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.

Etiology

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.

Epidemiology

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.

Sex distribution
Age distribution

Pathophysiology

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.

Prevention

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

Summary

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.

Patient Information

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.

References

Article

  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. 

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Last updated: 2017-08-09 18:07