Case Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

Subcutaneous hematoma under tension: a bedside intervention

Abstract

An elderly long-time nursing home resident was referred to the emergency department for altered mental status. There was no recent history of discrete trauma, but the patient’s ability to communicate was limited. She was noted to have a history of thrombocytopenia, and records revealed that she was being given one baby aspirin per day. No clear cause for the decline in mental status was discovered, but the patient was noted to have a purple subcutaneous hematoma on the forearm, which was circumferential and extended from the elbow nearly to the wrist. The lesion was tense, and cyanosis was noted distal to the lesion, indicating venous compromise. The pulse was intact. A longitudinal incision led to the extrusion of a large quantity of sanguineous fluid under pressure followed by manual expulsion of a large quantity of blood clot from the subcutaneous space; there was no Intramuscular hematoma. The hand immediately regained its normal appearance, and the incision was loosely closed. Complete workup was remarkable only for a hemoglobin level of 7.5 (reduced from previous values of N 9) and a stable platelet count of 30000. This entity, usually referred to a traumatic subcutaneous hematoma, is likely common in elderly nursing home patients (and is well described in postoperative patients) but has received little attention in the literature; there is no case series. Emergency department clinicians should be aware of the potential for such hematomas to cause vascular compromise and to be alert to the possibility of bedside intervention. A 78-year-old Asian woman was brought by ambulance to the emergency department (ED) for altered mental status. A nursing home resident for several years, she had severe dementia but was said to be able to recognize family members at times. She arrived unaccompanied,

Fig. 1. The cyanosis distal to the hematoma is evident.

0735-6757/(C) 2014

and the available records noted “idiopathic thrombocytopenic purpura and thrombocytopenia,” and it appeared she was on low-dose aspirin daily; there was no mention of recent falls or other recognized trauma. Vital signs were blood pressure 103/51 mm Hg; pulse of 84 beats per minute; respiratory rate, 20; and temperature of 37?C; the neurologic examination was remarkable for deep stupor, with no response to verbal stimuli and only withdrawal to noxious stimuli.

The only abnormal findings on physical examination were the presence of ecchymoses on the upper and lower extremities and on the forehead. The left forearm was noted to be markedly swollen, with a large, tense, circumferential ecchymosis with a subcutaneous hematoma extending from near the elbow to the wrist (Fig. 1). There was marked cyanotic discoloration distal to the hematoma, in striking contrast to the normal-appearing right hand (Fig. 1). The radial pulse was intact. A family member arrived and confirmed the worsened mental status and noted that the extremity and facial lesions were new, although the patient had a tendency “to bruise easily.” A head computed tomography had no acute findings; the most prominent laboratory abnormalities were a hemoglobin level of 7.5 mg/dL (a decrease from previous values of N 9) and a platelet count of 30000 per uL, essentially unchanged.

The extremely tense and circumferential nature of the extremity,

with obvious venous compromise caused concern that a compartment syndrome in the forearm could develop after admission to the Inpatient floor. A 10-cm longitudinal incision was made with immediate expulsion of a large quantity coagulated blood under high pressure. This was followed by the manual expulsion of a large quantity of organized hematoma from the subcutaneous tissue (Fig. 2). There did not appear to be any intramuscular hematoma. The hand

Fig. 2. The subcutaneous nature of the hematoma can be appreciated.

Fig. 3. Resolution of cyanosis with Primary repair of incision.

immediately regained its normal appearance, and the wound edges were easily approximated and closed lightly with 6 sutures (Fig. 3). The arm was wrapped in gauze and suspended; continued oozing was noted over the next 2 hours, and 3 U of platelets were transfused in the ED with resolution of all bleeding. The subsequent hospital course was uneventful; her mental status gradually improved to baseline, she received 1 U of Packed red blood cells, and was discharged back to the nursing home with follow-up at wound care clinic.

There is a remarkable paucity in the literature describing the causes and treatment of this entity, which is most often termed traumatic hematoma, traumatic subcutaneous hematoma, subdermal hematoma, or traumatic subcutaneous hematoma under tension. Previous cases (there is not even a case series of nonpostoperative cases) appear to suggest that it is most common in the elderly and those on anticoagulation [1]. In the large literature referring to compartment syndrome, it is routinely noted that compartment syndrome can occur after mild trauma or even exercise and that swelling from any cause, including hematoma, can precipitate the syndrome [2]. Standard textbooks of Emergency Medicine and

Surgery, however, do not refer to the type of putatively traumatic (rather than postoperative) subcutaneous hematoma that our patient exemplified. A common factor in both kinds of cases appears to be prolonged pressure in the absence of protective reflexes, either from general anesthesia or (as in our case) from a comatose state. The few cases reported note that there are 3 treatment options [1]. A longitudinal incision and drainage, such as we performed, appears to be the most common approach, but the use of wall suction devices [3], liposuction [4], and simple Needle aspiration [5] have also been used. All authorities agree that compartment syndrome may occur insidiously after seemingly minor trauma; in the unresponsive or insensate patient, a high index of suspicion is warranted. Our case suggests that simple bedside incision of a hematoma under tension may obviate this feared complication.

Christopher Wang, MD Nadia Baranchuk, MD Michael Heller, MD?

Department of Emergency Medicine, Mount Sinai Beth Israel Medical

Center, New York, NY

?Corresponding author. Mount Sinai Beth Israel Medical Center Department of Emergency Medicine, 5 Silver 16th St and 1st Ave

New York, NY 10003

Tel.: +1 610 216 2919; fax: +1 212 420 2862

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.04.028

References

1. Megson M. Traumatic subcutaneous hematoma causing Skin necrosis. BMJ Case Reports 2011. http://dx.doi.org/10.1136/bcr.05.2011.4273.
2. Olson SA, Glascow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005;13(7):436-44.
3. Karthikeyan GS, Vadodaria S, Stanley PRW. Simple and safe treatment of pretibial haematoma in elderly patients. Emerg Med J 2004;21:69-70.
4. Oliver DW, Inglefield CW. Liposuction of haematoma. Br J Plast Surg 2002;55 (3):269.
5. Chami G, Chami B, Hatley E, et al. Simple technique for traumatic subcutaneous haematoma evacuation under tension. BMC Emerg Med 2005;11.