Article, Intubation, Respiratory Medicine, Resuscitation, Traumatology

Life-threatening subcutaneous hematoma

Case Report

Life-threatening subcutaneous hematoma Abstract

Neurofibromatosis is rare Genetic disorder that predis-

poses patients to tumor formation. Although the clinical manifestations are variable, vascular malformations are known to occur. We report a case of life-threatening massive subcutaneous hemorrhage after minor trauma in a patient with neurofibromatosis. Physicians need to be aware that bleeding from vascular malformations, even in the subcutaneous space, may be life threatening.

A 36-year-old man presented by Emergency Medical Services to our emergency department (ED) with a chief complaint of swelling on his lower back. He was seen several hours earlier for a seizure. He had a head computed tomographic scan that was unremarkable as well as a basic metabolic panel that was normal. He was noted to have a small abrasion over his left eye and chronic weakness of his Left lower extremity. No other trauma was noted. About an hour after being discharged from the ED, his sister noticed swelling on his lower back and contacted Emergency Medical Service. Upon arrival, patient denied any pain or any new trauma. His medical history is significant for neurofibroma- tosis and seizures, which developed after a closed head injury 16 months prior. His medications included levetiracetam and baclofen. The patient also reported having an allergy to cephalexin and phenytoin.

Fig. 1 Large hematoma on back.

Fig. 2 Computed tomographic scan showing large superficial hematoma with extravasation of contrast.

On examination, the patient was lying prone on the stretcher. A large area of swelling was noted on his right flank area (Fig. 1). There were no abrasions or lacerations noted. His heart rate was noted to be 140 beats per minute, with an initial blood pressure of 91/41 mm Hg. A computed tomographic of the abdomen and pelvis was performed and showed a 36 x 13 x 37-cm superficial hematoma with extravasation of contrast in the right lower back (Fig. 2). The patient received approximately 6 L of normal saline with no improvement in his vital signs. Shortly afterwards, his blood pressure decreased to 71/40 mm Hg. Blood was ordered and transfused, and the patient had an emergent consult to vascular surgery. His initial hemoglobin was 11.7 g/dL. Three hours later, his hemoglobin decreased to 6.5 g/dL.

The patient was taken immediately to angiography, where multiple coils were placed in the lumbar arteries to control the hemorrhage from vascular malformations. During the first 48 hours, the patient required 24 units of pack red blood cells as well as multiple units of platelets and fresh frozen plasma. The patient was taken back to the operating room several more times for revisions of his wound. He was discharged from the hospital 58 days later.

Neurofibromatosis is a rare genetic disorder that is classified into 2 separate genetic disorders. This predisposes the patient to various tumors. However, the exact mechanism as to how this occurs is still unknown [1]. Clinical manifestations are wide and variable and can affect multiple

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organ systems. Vascular malformations are not uncommon and can lead to extensive bleeding [2]. There has been only 1 previous case of massive subcutaneous hemorrhage reported in a patient with neurofibromatosis [3]. However, this is the largest subcutaneous hematoma we could find in the literature. It is important for physicians to recognize that vascular malformations may occur in these patients and that even minor trauma may lead to Massive bleeding.

Bruce M. Lo MD Kirsten N. Pennell MD Rebecca M. Lipscomb MD

Department of Emergency Medicine Eastern Virginia Medical School Norfolk, VA 23507, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2007.09.005


  1. Lee MJ, Stephenson DA. recent developments in neurofibromatosis type 1. Curr Opin Neurol 2007;20(2):135-41.
  2. Tsuda M, Umebayashi Y, Manabe M, et al. A case of arteriovenous malformation with neurofibromatosis-1. J Dermatol 2006;33(2):158-9.
  3. Lin YC, Chen HC. Rare complication of massive hemorrhage in neurofibromatosis with arteriovenous malformation. Ann Plast Surg 2000;44(2):221-4.

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