From PODIATRY TODAY
February 27, 2020
Volume 33 - Number 3 - March 2020
Clinical Editor: Kazu Suzuki, DPM, CWS
Hematomas can occur in many clinical scenarios, including trauma and as a postoperative complication. Often, patients with hematomas have multiple medical issues as well as mobility issues that compound the challenges of a hematoma. Accordingly, these panelists discuss their experiences with treating and preventing hematomas.
Q: In what circumstances do you encounter hematomas that either cause or complicate a wound care case?
As patients age, there is a larger population at-risk for trauma or falls, notes Windy Cole, DPM, FACFAS. Combine that with multiple medical issues, thinner skin and possible anticoagulants, she adds, and traumatic soft tissue injuries put patients at risk for hematoma development. Dr. Cole says she frequently sees hematomas in the outpatient wound care center.
“Complications such as infection, skin loss, the need for surgical intervention and chronic, non-healing wounds are not uncommon,” shares Dr. Cole.
Kazu Suzuki, DPM, CWS, agrees that traumatic hematomas are frequent and common, especially in a more elderly or frail population, and as a result of ground-level fall injuries. Dr. Suzuki adds that in his experience, post-surgical hematomas are extremely rare due to meticulous hemostasis and frequent use of multilayer compression bandages after surgical cases, such as transmetatarsal amputation.
Despite similar efforts, Stephen Soondar, DPM, FACFAS points out a few instances in which a post-surgical hematoma can appear. He says post-op hematomas can occur after amputations when one has not used a drain or when a drain is ineffective. Post-op hematomas can also occur after the application of skin substitutes without employing concomitant negative pressure wound therapy (NPWT), according to Dr. Soondar.
Q: How do you approach hematomas from a wound care perspective? Are there any particular surgical techniques that you employ in the office or the OR? What types of local wound care might you use and at what stage of the treatment plan?
Dr. Suzuki states he always tries to drain the hematoma unless it is very minor and “flat.” He shares that in the office or the OR, he uses plain lidocaine local anesthesia, drains the hematoma freely and then irrigates with normal sterile saline using a large gauge syringe and 18-gauge needle. He states he also often uses a Saljet device (Winchester Laboratories), which comes in a convenient saline plastic packet.
“I stopped using pulse irrigation many years ago … due to concerns about airborne particles and aerosolization with a powered irrigation device,” says Dr. Suzuki.
All of the panelists agree with liberal evacuation and debridement of hematomas. Dr. Soondar relates his plan is usually to try to drain hematomas in the office when possible but he would not hesitate to return to the OR for aggressive attention to the site. He also finds locally that NPWT and silver alginate dressings can be helpful if the clinician initiates these modalities as soon as he or she identifies a hematoma.
Dr. Cole adds that if the patient in question is on anticoagulants, coordination with the prescribing physician is key for appropriate dosage and lab values. Small hematomas that one can manage conservatively may benefit from compression therapy, rest, anti-inflammatory medication and close monitoring, notes Dr. Cole. However, even though these less severe cases may resolve over a period of weeks to months, Dr. Cole says these hematomas can still cause considerable pain and inflammation, and should not be ignored.
Additionally, perioperatively, Dr. Cole has found that low-frequency ultrasound debridement is a useful tool for hematomas along with acellular dermal scaffolds to speed healing and decrease pain. She adds that NPWT can also assist with granulation tissue formation and the management of exudate in deeper hematomas with exposed deep structures.
Q:What can clinicians do to prevent hematomas, both in already existing wound cases and post-op cases?
Dr. Soondar shares several pearls for the prevention of hematomas.
“Try to use a drain whenever possible and possibly NPWT along with compressive and/or bolster dressings,” explains Dr. Soondar. “Be sure to cauterize or hand tie vessels intraoperatively, and let the tourniquet down when possible to assess bleeding.”
Topical thrombin and Gelfoam® (Pfizer) are also helpful, according to Dr. Soondar. He also recommends fenestration of any skin substitutes both before application and postoperatively.
With respect to the use of a drain, Dr. Suzuki shares a different experience. He stopped using Jackson-Pratt (JP) drains after transmetatarsal amputations and many reconstructive cases as he felt they were often adding extra OR time and possibly creating a portal of entry for contaminants. Instead, for the last 10 years, Dr. Suzuki has preferred meticulous hemostasis with electrocautery prior to flap or wound closure along with subsequent use of a multi-layer compression bandage such as Comprifore®. This dressing gently squeezes out any residual hematoma and Dr. Suzuki finds this achieves similar results to the Jackson-Pratt drain with less fuss and less time.
Dr. Cole adds that careful, non-traumatic tissue handling intraoperatively may prevent continued post-op bleeding, which is a risk with any amputation or aggressive debridement.
When it comes to preventing hematomas, focusing on fall risk and gait abnormalities is important, notes Dr. Cole. She emphasizes performing a fall risk assessment for any new patient.
“Although offloading is the cornerstone of management of diabetic foot ulcers, not all patients can safely ambulate in a total contact cast or cast boot, and accommodations may be necessary to prevent injury,” explains Dr. Cole.
Dr. Cole is an Adjunct Professor and Director of Wound Care Research at the Kent State University College of Podiatric Medicine. She is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Soondar is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons. He is the Assistant Director of the Phoenixville Hospital Podiatric Residency Program in Phoenixville, Pa., and is in private practice in Media, Pa.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, CA. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles, CA. He can be reached at [email protected].