Hematoma

Hematoma Facts

• Hematomas form when a blood vessel leaks into the surrounding tissue.
• If a person experiences trauma and develops symptoms such as confusion, intense headache, uneven pupils, or other neurological signs, seek immediate medical care.
• Medical care and treatment of a hematoma will depend upon its location, what body parts are affected, and what symptoms are present.

• A hematoma is a collection of blood, usually clotted, outside of a blood vessel that may occur because of an injury to the wall of a blood vessel allowing blood to leak out into tissues where it does not belong. The damaged blood vessel may be an artery, vein, or capillary; the bleeding may be very tiny, with just a dot of blood, or it can be large and cause significant blood loss.
• A hematoma is a type of internal bleeding that is either clotted or forming clots. Hemorrhage is the term used to describe active bleeding and is often graded on a severity score of one to four (representing 15% to >40% of total blood volume).
• Hematoma describes bleeding that has already started to become clotted. However, the distinction sometimes is not clear as some hematomas enlarge over time, and active bleeding can add to the mass of the hematoma.
• Hematomas are often described based on their location in the body, whether in the skull (intracranial), under the fingernail (subungual), or in the earlobe.
• Hematomas of the skin may also be named based on their size. Petechiae are tiny dots of blood usually less than 3 millimeters in diameter (0.12 inch) while purpura is less than 10 millimeters in diameter (0.40 inch) and ecchymosis is greater than 10 millimeters in diameter. Ecchymosis is commonly considered a bruise.
• A hematoma forms when a blood vessel leaks into the surrounding tissue. The injury to a blood vessel wall may occur spontaneously or may be due to injury. The violence of a sneeze or cough may cause blood vessels in the face to break and cause small amounts of bleeding.
• The body is usually able to repair the damaged vessel wall by activating the blood clotting. Sometimes the repair fails if the damage is extensive and the large defect allows for continued bleeding or if the person has problems with blood clotting. If the bleeding occurs in a tiny capillary blood vessel, only a drop or two of blood may be lost into the surrounding tissue causing petechiae to form.
• If there is significant pressure within the blood vessel, for example, a major artery, the blood may continue to leak and cause an expanding hematoma that causes significant blood loss and shock.
• Blood that escapes from the bloodstream is very irritating and may cause all the symptoms of inflammation including pain, swelling, and redness. Symptoms of a hematoma depend upon their location, size, and whether they cause associated swelling, edema, or pressure on adjacent structures such as blood vessels and nerves.

Hematomas are usually caused by trauma, whether it is the result of a car accident, a minor bump, a cough, or an unknown event. The blood within blood vessels is continually flowing and therefore does not clot or coagulate. When blood leaves the circulatory system and becomes stagnant, there is almost immediate clotting. The greater the amount of bleeding that occurs, the larger the hematoma.

Anticoagulant medications, including aspirin, warfarin (Coumadin), clopidogrel (Plavix), and dipyridamole (Persantine) may be associated with blood clots. Diseases or infections may occur that decrease the number of platelets in the bloodstream or their ability to function. The platelets are the cells that help initiate blood clotting. If platelets are inhibited, bleeding can continue and hematomas can develop and expand. Examples of bacterial infections, autoimmune diseases, and other situations that may lead to hematomas include:

• Finger infections
• Ankylosing spondylitis
• Onychomycosis
• Hematomas of the ear may occur if an injury causes bleeding to the cartilage structure of the ear. A common complication of ear hematomas is cauliflower ear.
• Septal hematoma may occur due to nose injuries. A septal hematoma may form associated with a broken nose, and if not recognized and removed, the cartilage can break down and cause a perforation of the septum.
• Internal bleeding into the abdomen may be life-threatening depending upon the cause and the situation and lead to irritation of the lining of the stomach.
• Hematomas may occur in solid organs like the liver, spleen, and kidney, or they may occur within the walls of the small intestine or colon. Hematomas may also form within the lining of the abdomen or behind the space where the kidneys are located.
• Orthopedic injuries or broken bones may cause hematomas. Bone marrow is where much of the body's blood production occurs, and a fracture may cause significant blood loss.
• Compartment syndrome is an uncommon complication of bleeding and hematoma due to injury. This is an orthopedic emergency as it requires surgery to correct. Symptoms of compartment syndrome include intense pain made worse with the movement of the fingers or toes and numbness and tingling of the extremity with decreased pulses in the hand, leg, or foot.
• Pregnancy is associated with subchorionic hemorrhage about 25% of the time. It is the most common abnormality seen by sonographic analysis in pregnant women. Most small to moderate hematomas regress and do not worsen the patient's prognosis. Blood clots and/or bleeding in the third trimester may be a sign of problems such as placenta previa or placental abruption and is considered a medical emergency.

There are many different types of hematomas, and they are described by the location of the hematoma. Examples include the following:

Intracranial Hematomas

Intracranial hematomas can be epidural (above the epidural membrane), subdural (below the epidural membrane), intracerebral (within the brain tissue), or subarachnoid (between the pial and arachnoid membranes in the brain). Although a few intracranial hematomas may remain small and not significantly compromise brain tissue, most intracranial hematomas are considered to be a medical emergency because they can compress brain tissue and blood vessels resulting in significant brain damage.

Symptoms of intracranial hemorrhage and/or hematoma depend upon where the brain is affected. General symptoms include altered consciousness, nausea and vomiting, headache, focal neurological deficits, and neck stiffness, and some patients may have seizures and/or coma.

In most patients, intracranial hematoma that produces symptoms is considered a medical emergency, and specialized medical professionals (neurosurgeons) are consulted urgently.

Picture of an epidural, subdural, and intracerebral hematomas

Subungual Hematomas

An injury to the bed of a finger or toenail may cause a subungual hematoma. This type of hematoma typically causes significant pain because it is trapped in a small space that does not allow room for the bleeding to expand. The treatment may include burning a small hole through the nail itself to allow the blood to drain.

Picture of a subungual hematoma

Hematomas cause irritation and inflammation. Symptoms depend upon their location and whether the size of the hematoma or the associated swelling and inflammation cause nearby structures to be affected. The common symptoms of inflammation include:

• Redness
• Pain
• Swelling

Hematomas tend to resolve over time:

• The initial firm texture of the blood clot gradually becomes more spongy and soft as the body breaks down the clot.
• The shape changes as the fluid drain away and the hematoma flattens.
• The color changes from that of a purplish-blue bruise to yellows and browns as the blood clot degrades and the hematoma resolves.

Head and physical trauma injuries may cause life-threatening bleeding and hematomas. Seek medical care if the individual experiences the following symptoms after a head or other traumatic physical injury:

• Severe headache associated with nausea, vomiting, and confusion
• Loss of consciousness
• Uneven pupils
• Inability to move a leg or an arm
• Excessive sleepiness
• Hearing loss
• Difficulty swallowing

Hematomas may occur commonly and some have little importance while others are life-threatening. Many times it is a matter of location and situation that makes the hematoma a critical condition instead of an inconvenience.

Most hematomas are due to minor trauma and the patient is aware of the injury and its circumstances. Most resolve without any consequence and need no evaluation. However, if a person develops symptoms such as confusion, intense headache, uneven pupils, or other neurological signs after any trauma, seek medical care immediately.

It is important to pay attention to specific hematomas because of their complications. Always take head injuries seriously because a small amount of blood and clot can cause significant pressure changes within the skull and perhaps lead to brain damage.

Blood clots are not normal in the urine or in bowel movements because they may be associated with significant bleeding. Blood in these locations may be associated with infections, cancers, tumors, or other lesions that can be life-threatening, but potentially curable if found early. (Please note that bladder infections may be associated with hematuria or blood in the urine and may not need further evaluation once the infection has been treated; clot and hematoma formation is rare.)

While most people have bruising as a common injury due to the minor accidents of daily life, some people with bleeding disorders where their blood lacks certain clotting factors may develop unexplained bruising and bleeding and may benefit from seeking medical care. Similarly, patients who take blood thinners are at higher risk of bleeding from minor injuries and should seek medical attention if they sustain even minor injuries.

Most hematomas can be evaluated and safely treated without laboratory or radiology tests. Often the healthcare professional will be able to take a history and perform a physical examination and decide that no further evaluation is required.

However, depending upon the injury or presentation, blood tests may be ordered, including a hemogram to assess the red blood cell count (often the hemoglobin and hematocrit are measured) and clotting studies, including an international normalized ratio (INR), and partial thromboplastin time (PTT), a blood test that measures how long it takes for blood to clot. The INR is routinely measured in individuals taking the blood thinning medication, warfarin, to help monitor the individual's medication dosing.

Depending upon the site of injury or other associated factors, the healthcare professional may request additional testing. CT scans are useful in looking for blood in the brain or abdomen. Ultrasound is often used for pregnant patients who have vaginal bleeding.

Most hematomas of the skin are caused by contusions and can be treated with rest, ice, compression, and elevation (RICE). They will gradually resolve over time. Depending upon the location, immobilization of the area for a few days may speed healing, but there needs to be a balance between healing and retaining the range of motion of the affected body part.

Over-the-counter (OTC) pain medications including acetaminophen and ibuprofen may be useful in controlling inflammation and pain. It is important to remember that even OTC medications have side effects and their use should be discussed with a healthcare professional or pharmacist. For example, patients taking blood thinners should be cautious about taking ibuprofen because of the risk of stomach bleeding while patients who have liver disease should carefully monitor the amount of acetaminophen they take.

Medical care and definitive treatment of a hematoma depend upon its location, what body parts are affected, and what symptoms are present.

For example, a small hematoma of the brain may be observed if the patient is fully awake, while another patient with a head injury may require an operation to save brain tissue. The same may be true with a patient with an intra-abdominal hematoma. If the patient is stable, observation may be appropriate, but if shock develops, some surgical intervention may be required.

Most hematomas resolve spontaneously and need no further evaluation.

Since blood is a rich medium full of nutrients, some hematomas may become infected. Individuals with a hematoma should monitor for signs of increased pain, warmth, and redness. This may be difficult to differentiate from the symptoms of inflammation of the hematoma itself. However, infections often are associated with fever; and pus and red streaking that develop around the hematomas give clues that an infection is brewing.

Patients taking blood thinners may be at risk for continued bleeding and the amount of bleeding may need to be monitored by repeated blood tests measuring the hemoglobin and INR.

Accidents happen and most hematomas are inevitable.

For persons taking anti-coagulation medications, it is wise to avoid participating in events with a high risk of injury. For patients taking warfarin (Coumadin), it is important to monitor the medication dosing on a regular basis to keep the blood thinned and the INR in the appropriate range for the disease being treated.

• Blood vessels are routinely injured and may leak blood, causing hematomas or blood clots.
• Depending upon their size and location, hematomas may be insignificant or may cause life-threatening damage.
• People who take blood thinners like warfarin (Coumadin) and clopidogrel (Plavix) are at higher risk of bleeding from minor injuries.
• Most hematomas resolve by themselves and need no further treatment, but some may require surgical treatment.
• Take injuries to the head seriously because of the risk of bleeding causing injuries like epidural, subdural, and intracerebral hemorrhage.