Married to husband Kevin for 6 years
Reside in Lebanon, IN
3 dogs and 2 cats
Graduated from IU School of Nursing in 2007
MSN from Indiana State University 2012
NP at Center for Healthy Aging April 2013-December
2014
• NP at Excell for Life Family and Pediatrics December
2014-present
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• There are no relevant personal financial relationships
“The only source of knowledge is experience.”
Albert Einstein
A localized swelling that is filled with blood caused by a
break in the wall of a blood vessel. The breakage may be
spontaneous or caused by trauma. Bleeding disorders and
anticoagulation therapy can contribute to hematoma
formation.
Elderly population is at risk due to
• Increased use of anticoagulation
• Polypharmacy
• Immobility/increased risk for falls
• Neuropathy
• Vascular disease
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Tender/painful
Warm
Erythema or ecchymosis
Localized swelling/ palpable mass
Positive Homan’s sign
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Hematoma
Deep Vein Thrombosis
Ruptured popliteal cyst
Infection
Sarcoma
Lymphedema
“Coup de fouet” syndrome
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CBC
PT/INR, other coagulation studies
Ultrasound/venous doppler
Venography
Computed tomography (CT)
Magnetic resonance imaging (MRI)
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Stop anti-coagulants
Blood products
Pain control- avoid NSAIDS
Surgical Excision
Monitor closely may reabsorb spontaneously
If suspicion for concurrent infection- antibiotics
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Compartment syndrome
Tissue Necrosis
Infection
Loss of limb
Case Study #1
75-year-old white
male
Medical History
Hypertension
Chronic atrial fibrillation
Peripheral vascular
disease
Medications:
Aspirin
Digoxin
Prazosin
HCTZ
Lisinopril
Potassium
Salsalate
PE:
Mild erythema on posterior aspect of calf
Warmth
Swelling
Diffuse tenderness
Ecchymosis distally at level of the malleoli
Positive Homan’s sign
Laboratory data:
WBC 8.2
ESR 35mm/hr
Coagulation parameters normal
Treatment:
Started on a course of oral erythromycin for presumed cellulitis.
No improvement in symptoms after 3 days, worsening pain and
swelling.
Ultrasound did not reveal DVT or a mass.
Pt. admitted to the hospital and given IV ampicillin.
5 days later a repeat ultrasound demonstrated a posteromedial
calf mass.
MRI showed a hematoma deep with in the gastrocnemius.
Patient was referred for surgical evaluation and 300ml
hematoma was evacuated. The patient was discharged on POD
#2 and fully recovered by 8 months post op.
Case Study #2
63-year-old male
Medical History:
History of hepatitis
Atrial septal defect repair
Mitral valve replacement
Acute arterial embolic
episodes of the extremity
Medications:
Warfarin
Aspirin (other meds unknown)
PE:
Local tenderness
Slight swelling of inner-anterior
aspect of right thigh
Ultrasound revealed a hematoma within the vastus medialis
muscle
Warfarin was stopped for 3 days and the symptoms subsided
after conservative management for 2 weeks.
5 years later patient was readmitted to the hospital with severe
pain in the right lower leg. Pt continues on warfarin and aspirin.
PE: peripheral arterial pulses easily palpable
Leg swelling
INR 3.59
CT scan revealed a very large hematoma in the right soleus and
gastrocnemius muscles.
Anticoagulation therapy was held for 7 days.
50mls of dark bloody fluid was obtained by needle
puncture.
Patient’s symptoms completely resolved at time of
discharge.
• Case Study #3
• 81-year-old female
• Medical history:
• Congestive heart failure
• Atrial fibrillation
• Right total knee replacement
Medications:
Warfarin
Aspirin
• Patient diagnosed with spontaneous expanding right
medial lower leg hematoma and referred to wound
services on day 4.
• Due to the rapid expansion of the hematoma patient was
referred for surgical treatment.
• Patient required surgical excision down to the muscle
fascia with hematoma evacuation.
Case Study #4
93-year-old white
female
Medical hx:
Recently discharged
from hospital after
treatment for cardiac
arrest
Diabetes
Hx of DVT
Hx Bilateral PE
Dementia
Medications:
Warfarin- new start with last 30 days
Lexapro
Donepezil
Levemir
Levothyroxine
Namenda
Oxycodone
Zinc
Polyethlene glycol
PE:
Left lower extremity pitting edema
Tender echymotic mass
Erythema
Increased warmth
Lab data:
Elevated blood glucose 300-500
INR 2.1
Venous doppler negative for DVT
Started on oral keflex for presumed cellulitis
No improvement in symptoms 24 hours after antibiotics started
48 hours later nurse concerned that leg was getting worse- more
edema, skin darkening
Admitted to the hospital, CT scan indicated large soft tissue hematoma.
Repeat venous doppler negative. Hgb 7, WBC 13. 2units PRBC. IV
antibiotics were continued throughout her hospital stay.
I and D, surgical debridement and skin grafts later discharged to ECF.
Case Study #5
85-year-old female
Medical History:
Recent CVA with
left sided hemiparesis
Atrial fibrillation
HTN
HLD
.
Medications:
Warfarin new start
within last 30 days
aspirin
Flexeril
Hydrocodone/apap
Vitamin D3
Cyclobenzaprine
Ferrous fumarate
Lisinopril
Metoprolol
Vitamin C
Digoxin
Pt c/o severe pain radiating from left hip down her leg not relieved with
hydrocodone.
ROM at hip limited by pain
Leg tender to palpation
No erythema
No edema
No increased warmth
Lab data:
CT scan showed large hematoma poster to hip and along hamstring.
INR “slightly elevated”
Hgb 10
Coumadin was held
3 days later SBP dropped to 70 and pt developed dizziness. BP meds were held and
po fluids encouraged, when symptoms persisted she was sent to ER.
Hgb 9.7
INR 1.28
Mildly elevated bilirubin
Given IV fluids and BP meds doses cut in 1/2.
Coumadin held until hematoma resolved.
Started on
warfarin within
30 days of
hematoma
Supra-therapeutic
INR at onset of
symptoms
Comorbidities
Drug interaction
with warfarin
increase risk of
bleeding
Case #4
Case #5
Case 1,2,3
unknown
Case #2
Case #5
CVD: MI, CVA,
HTN, PVD, Afib,
valve disease
Diabetes: case #4
Dementia: case #4
Depression: case #4
Aspirin: #1*, #2,
#3, #5
SSRI: #4
*Case 1 not on warfarin, asa
only.
Choi, J., Kwon, J. H., Choi, B. K., Shin, S. J., Kim, K. S. &
Lee, J. K.
(2009). Enoxapain-induced spontaneous
thigh bleeding in
a hemodialysis patient. The Korean
Journal of Nephrology,
28, 360-364.
Hoffman, R. D. & Buckwalter, J. A. (n.d.) Spontaneous calf
hematoma: A refort of two cases diagnosed with
MRI. The
Iowa Orthopaedic Journal,18, 142-145.
Hylek, E. M., Evans-Molina, C., Shea, C., Henault, L. E. &
Regan, S.
(2007). Major hemorrhage and tolerability of
warfarin in the first year of therapy among elderly
patients with atrial fibrillation. Circulation, 115, 2689-2696.
doi:10.1161/CIRCULATIONAHA.106.653048
Pagan, M. & Hunter, J. (2011). Lower leg hematomas:
Potential
for complications in older people. Wound
Practice and Research, 19(1), 21-28.
Sakakibara, Y., Shizu, A., Yoshiharu, E., Motoo, O.,
Hiramatsu, Y., Shigeta, O., . . . Mitsui, T. (1999). Lower
extremity hematoma as a complication of warfarinization in
patients with artificial heart valves. Jpn Heart J, 40, 239245.