Postoperative Haematoma

Postoperative haematoma is a localised collection of blood in the operative field or surrounding tissue. It ranges from a minor wound bruise to a life threatening airway or compartment problem.

Epidemiology. Wound haematoma occurs in about 1% to 5% of operations. Neck haematoma after thyroid and parathyroid surgery occurs in about 0.3% to 4%, and after carotid endarterectomy in 1% to 5%. Most neck haematomas appear within 6 hours.

Causes and risk factors. Inadequate haemostasis, anticoagulant and antiplatelet use, hypertension, coagulopathy, thrombocytopenia, vomiting or coughing, large dead space, and previous radiation. Male sex, age and extensive dissection add risk in neck surgery.

Sites of concern. Neck (airway), spinal canal (cord or cauda equina compression), retroperitoneum, breast flap, free flap pedicle, pelvis, thigh, forearm (compartment syndrome) and cranial.

Pathophysiology.

Bleeding into a closed space raises tissue pressure. In the neck, venous and lymphatic obstruction causes laryngeal and pharyngeal oedema, so airway obstruction can occur even with a small volume.

In a fascial compartment, rising pressure impairs perfusion and nerve function.

Swelling, tense or bruised tissue, pain, wound leakage, drain output rise or sudden stop, and local warmth. In the neck: stridor, dysphagia, voice change, dyspnoea, tight dressings and anxiety. In the spine: new back pain, weakness and sphincter loss.

Red flags.

• Neck swelling with stridor, voice change or respiratory distress.
• New neurological deficit after spinal surgery or neuraxial block.
• Pain out of proportion in a limb with tense swelling.
• Expanding pulsatile mass.
• Flap discolouration or loss of Doppler signal.
• Haemodynamic instability.

Clinical diagnosis for superficial and neck collections. Ultrasound confirms depth and size. MRI is needed urgently for suspected spinal haematoma. CT angiography is used for retroperitoneal or deep bleeding. Check haemoglobin, platelets and coagulation, and review anticoagulants.

Differential diagnosis.

• Seroma.
• Abscess.
• Cellulitis.
• Oedema.
• Lymphocele.
• Pseudoaneurysm.
• Tumour recurrence.
• Airway oedema from anaphylaxis or angioedema.

Neck haematoma with airway compromise. Call for senior help. Give oxygen. Open the skin, platysma and strap muscles at the bedside to release pressure, and evacuate clot, since this often relieves obstruction before intubation. Intubate by an experienced operator with awake or sedation sparing technique and a difficult airway set. Return to theatre for haemostasis.

Spinal haematoma. Emergency MRI and neurosurgical decompression, ideally within 8 hours of onset of deficit. Reverse coagulopathy.

Compartment syndrome. Remove constrictive dressings, keep the limb level with the heart, and proceed to fasciotomy for confirmed or clinically evident compartment syndrome.

Small superficial haematoma. Observe, apply pressure, and use cold compresses for 24 to 48 hours. Evacuate if expanding, tense, painful, threatening wound closure or flap viability, or infected.

• Paracetamol: 1 g orally or IV every 6 hours (over 50 kg) for 3 to 5 days as needed; maximum 4 g in 24 hours; use 2 to 3 g daily if under 50 kg, malnourished, chronic alcohol use or hepatic impairment; check liver enzymes if used beyond 3 days at high dose.
• Avoid nonsteroidal anti-inflammatory drugs while bleeding persists.

Reverse bleeding tendency with tranexamic acid, platelets, fibrinogen, protamine or specific antidotes as appropriate. Review timing for restarting anticoagulants with the surgeon, usually 48 to 72 hours after haemostasis is secure.

Infected haematoma. Drain and treat with cefalexin 500 mg orally every 6 hours or flucloxacillin 500 mg to 1 g orally every 6 hours for 5 to 7 days; maximum flucloxacillin 4 g daily orally; monitor liver enzymes (cholestatic hepatitis risk, particularly in older adults and courses over 14 days); reduce interval in creatinine clearance under 10 mL/min; in penicillin allergy use doxycycline 100 mg orally twice daily for 5 to 7 days (maximum 200 mg daily; avoid in pregnancy).

Monitoring. Wound and neck circumference marked and timed, drain output, haemoglobin, neurovascular checks every 15 to 60 minutes for limbs and spine, and flap perfusion.

Referral and escalation. Immediate surgical review for any expanding haematoma. Anaesthetic and ENT airway review for neck swelling. Neurosurgical review for neurological signs.