Can a breast hematoma lead to hemorrhagic shock in elderly trauma patients with multiple comorbidities and reduced physiological reserve? Examining the risks and management strategies

Abstract

Breast trauma in elderly patients with multiple comorbidities can result in severe complications such as hemorrhagic shock due to the highly vascular nature of breast tissue. This case involves a 65-year-old female with a history of rheumatoid arthritis and prior breast cancer who developed a significant breast hematoma following a motor vehicle accident. Initially stable, she rapidly deteriorated with hypotension and altered mental status after imaging revealed a large hematoma with active hemorrhage. Immediate intervention, including blood transfusion and intubation, was essential for stabilization. While spontaneous cessation of bleeding and hematoma stabilization can negate the need for further intervention, persistent bleeding requires prompt action. Options include surgical exploration, hematoma evacuation, vessel ligation, interventional radiology for embolization, additional blood transfusions, and pharmacological hemostatic agents. Breast hematoma can lead to hemorrhagic shock if severe enough in elderly patients with reduced physiological reserve.

Introduction

Breast trauma, while less common than other types of injuries, presents unique challenges due to the highly vascular nature of breast tissue [1]. Following trauma, significant bleeding can lead to the formation of a hematoma, which is a localized collection of blood outside of blood vessels [1]. Breast hematomas can vary in size and severity, with larger hematomas potentially causing considerable pain, swelling, and bruising [2]. Prompt diagnosis and management of breast hematomas are crucial to prevent complications, including infection and ongoing bleeding [2].

Hemorrhagic shock is a life-threatening condition that occurs when there is significant blood loss, leading to inadequate tissue perfusion and oxygenation [3]. In the context of breast trauma, the extensive vascularity of the breast tissue means that a substantial volume of blood can accumulate within a hematoma [4]. It is estimated that a patient can lose up to 20% of their blood volume into the breast before becoming hypotensive [5]. For an average adult with a total blood volume of approximately 5 liters, this translates to around 1 liter of blood loss [6]. Recognizing the signs of hemorrhagic shock and initiating rapid resuscitation measures, including blood transfusion and supportive care, are critical steps in the management of these patients [7]. While trauma remains a primary cause of breast hematomas, iatrogenic injuries—such as those resulting from vacuum-assisted biopsies (VAB) or vacuum-assisted excisions (VAE)—are also recognized sources of severe hemorrhage, particularly in older patients with calcified vessels [8]. These procedures can lead to significant bleeding, especially in elderly patients who may already have reduced vascular integrity [9].

The advanced trauma life support (ATLS) protocol is a cornerstone in the initial assessment and stabilization of trauma patients [10]. It ensures a systematic evaluation of airway, breathing, circulation, disability, and exposure. Continuous monitoring and reassessment are essential to detect changes in a patient's condition and initiate timely interventions [11].

The multidisciplinary nature of trauma care cannot be overstated. Collaboration among emergency medicine, trauma surgery, radiology, intensive care, and rehabilitation services ensures comprehensive and holistic management of trauma patients [12]. Each specialty contributes to the overall treatment plan, addressing both acute and long-term needs.

Additionally, the cardiovascular system undergoes significant changes with age, such as decreased cardiac output and vascular elasticity, which reduce the body's ability to respond effectively to bleeding [13]. These changes, combined with a diminished physiological reserve, make elderly patients more susceptible to severe complications from trauma [14]. Understanding these age-related alterations is crucial for tailoring interventions and anticipating potential complications in trauma management.

Case presentation

A 65-year-old female with a significant medical history presented to the emergency department (ED) as a full trauma alert following a single-vehicle accident. Her medical history included juvenile rheumatoid arthritis, intraductal carcinoma and lobular carcinoma in situ (LCIS) of the left breast, and recurrent major depressive disorder (MDD).

The patient was a restrained driver and was found ambulatory at the scene with her car in a ditch and on fire. She was not exposed to fire or smoke. EMS noted swelling and bruising in her right anterolateral chest wall, with her only complaint being pain in that area. She had stable prehospital vital signs and reported consuming alcohol earlier in the day. The advanced trauma life support (ATLS) protocol was followed upon arrival at the ED. The primary survey revealed an intact airway, slightly diminished bilateral breath sounds over the right anterior chest wall, strong radial pulses, warm, perfused distal extremities, and a Glasgow Coma Scale (GCS) of 15. The Extended Focused Assessment with Sonography for Trauma (E-FAST) was limited by the inability to obtain cardiac views. Still, it showed no free fluid in the right upper quadrant, left upper quadrant, or pelvis. The secondary survey revealed a large hematoma overlying the right superolateral chest wall and shoulder area and tenderness to palpation overlying the right rib cage. The abdominal exam showed a soft abdomen with no tenderness and no tenderness in the cervical, thoracic, or lumbar spine.

CT imaging (see Fig. 1, Fig. 2, Fig. 3, Fig. 4) revealed a large hematoma in the right breast with contrast blush, indicating active hemorrhage and no acute abnormalities of the lungs, mediastinum, abdomen, or pelvis. The patient was given 100 mcg of fentanyl for pain management and remained stable initially. However, following the CT scan, she developed acute hypotension and altered mental status, necessitating an acute blood transfusion with I Unit of whole blood and subsequent intubation due to ongoing decreased GCS. Central venous access was obtained via the right femoral vein, and a breast binder was placed. Notably, the patient was not on any anticoagulant medication before the accident.

Fig. 1.

CT chest with IV contrast (axial view) demonstrating a substantial hematoma in the right breast (red square).

Fig. 2.

CT chest with IV contrast (axial view) revealing active extravasation, indicative of active hemorrhage in the affected area (red square).

Fig. 3.

CT trauma chest, abdomen, and pelvis with IV contrast (sagittal view) with a large hematoma (red square).

Fig. 4.

CT trauma chest, abdomen, and pelvis with IV contrast (coronal view) a large hematoma. The hyperdense area correlates with the extravasation seen in the axial view, indicating active hemorrhage (red square).

The patient was admitted to the Surgical Trauma Intensive Care Unit (STICU) for altered mental status (AMS) and hypotension secondary to hemorrhagic shock from the right breast hematoma. On the first day in the STICU, she became hypotensive, with blood pressure dropping to the 40s systolic. She received 1 unit of packed red blood cells. The following day, all lines were removed, she was extubated and started on a regular diet. She was transferred to the floor later in the evening, with a CBC scheduled for the following morning.

While the differentiation between a breast-related hematoma and a potential traumatic pectoralis major rupture is indeed an important consideration, the clinical and radiological findings in this case pointed more strongly toward a breast hematoma. The clinical exam, combined with the location and characteristics of the hematoma on imaging, suggested that a traumatic muscle rupture was less likely.

On the third day, her hemoglobin dropped from 9.3 to 12.7. Her vital signs were stable overnight, and she was tolerated a diet well the next morning. She was continued on monitoring for symptomatic anemia. By the fourth day, her hemoglobin remained stable, and deep vein thrombosis (DVT) prophylaxis that was previously held, was initiated with Lovenox. Physical and occupational therapy were also started. On the fifth day, her hemoglobin remained stable, and her oxygen saturation (SpO2) was good on room air. She was discharged with a close follow-up plan.

Discussion

In managing breast trauma, particularly in elderly patients with multiple comorbidities, understanding the dynamics of hemorrhagic shock and its management is crucial. Hemorrhagic shock occurs when significant blood loss leads to inadequate tissue perfusion and oxygenation [15]. This patient's rapid deterioration, marked by the presence of hypotension and altered mental status, emphasizes the urgency of the situation and the severity of the condition. Hemorrhagic shock was promptly identified and managed through intensive measures, including blood transfusion and intubation, to secure the airway and support breathing due to the severe drop in the patient's Glasgow Coma Scale (GCS) score.

Intubation was necessary as the patient's altered mental status from shock impaired her ability to maintain a clear airway, and ensuring proper ventilation was essential to support her overall stability [10]. Intubation also protects potential airway compromise in the setting of ongoing severe hypotension and altered consciousness.

The management of a breast hematoma involves a nuanced approach. Initial steps include the application of a breast binder, monitoring, and supportive care, particularly if the bleeding stops spontaneously and the hematoma is stable. However, if bleeding continues or if there is evidence of expanding hematoma, further intervention becomes necessary. Surgical options include exploratory surgery to identify and control bleeding sources, hematoma evacuation to relieve pressure and prevent complications, and vessel ligation to address the source of hemorrhage directly.

Interventional radiology offers minimally invasive alternatives such as embolization to occlude bleeding vessels and control hemorrhage without the need for open surgery [16]. Additional measures, such as continuous blood transfusion and hemostatic agents, may also be employed to manage persistent bleeding [6].

Indications for surgical intervention typically include ongoing bleeding that does not respond to conservative management, evidence of expanding hematoma, or signs of persistent hemodynamic instability despite adequate resuscitation [17]. Surgical exploration is warranted if noninvasive measures fail to stabilize the patient or if imaging reveals significant active hemorrhage that poses a high risk of deterioration. Surgical options include exploratory surgery, hematoma evacuation, and vessel ligation [18].

The decision not to involve surgeons or interventional radiology (IR) despite the presence of active bleeding (contrast blush) on the CT scan likely reflects a careful assessment of the patient's overall condition and the dynamics of the hematoma. In some cases, when bleeding appears contained and the patient stabilizes after initial resuscitation, a conservative approach may be preferred to avoid unnecessary invasive procedures [19].

In this case, it was decided by the team to continue with conservative management because the patient responded well to resuscitation measures, including blood transfusion and supportive care, and the hematoma was not rapidly expanding. Conservative management is often favored if there is evidence that the bleeding has slowed or ceased, the patient remains hemodynamically stable, and there are no immediate signs of further deterioration. Additionally, elderly patients with multiple comorbidities and reduced physiological reserves may be at higher risk for complications from invasive procedures, such as surgery or embolization, which may lead the team to prioritize noninvasive approaches unless necessary [13,20].

Close monitoring in these cases is critical, with plans to intervene surgically or via IR if the patient's condition worsens or if the bleeding does not resolve on its own [16]. This approach allows for a balance between avoiding unnecessary risks and maintaining readiness for further intervention if required.

In addition to trauma, iatrogenic causes of breast hematomas, such as those following vacuum-assisted biopsies (VAB) or vacuum-assisted excisions (VAE), are particularly relevant in elderly patients [8]. These procedures can lead to significant bleeding, especially in older individuals with calcified vessels, which are more prone to injury [21]. Such cases can result in large hematomas that may require further intervention. Interventional radiology (IR) is a valuable option for managing these situations by embolizing the bleeding vessels, commonly branches of the internal mammary or lateral thoracic arteries [22]. This approach effectively controls the hemorrhage and often reduces the need for invasive surgery.

The CT images presented in this case show a significant collection in the right pectoral region, raising the possibility of involvement of the pectoralis major muscle. Given the size and location of the hematoma, the team considered whether the bleeding originated from the breast tissue or from a traumatic rupture of the pectoralis major muscle, and this differential diagnosis was explored and discussed. However, the traumatic rupture of the pectoralis major muscle was deemed less likely based on the clinical exam, which did not show signs consistent with muscle rupture [23].

A notable consideration in this case was the option of performing angiography, particularly given the active contrast extravasation seen on imaging, which suggested ongoing bleeding [24]. Angiography could have precisely identified the source of the hemorrhage and facilitated selective arterial embolization, providing immediate control of the bleeding [25]. This intervention would have been especially beneficial, potentially allowing for the safe reintroduction of anticoagulation therapy if needed [26]. Although this option was discussed, unfortunately, angiography was not available at the time of the patient's presentation, limiting the immediate treatment options.

In cases where the bleeding has ceased and the hematoma is stable, patients can often be managed with close observation rather than immediate surgical intervention. Continuous monitoring includes assessing vital signs, labs, repeat imaging if needed, and tracking changes in the patient's condition to ensure no further intervention is required.

Conclusion

Effective management of breast hematomas and hemorrhagic shock requires a balance of immediate intervention and ongoing monitoring. The extensive vascularity of breast tissue can lead to significant blood loss, highlighting the need for early recognition and management of complications. This case underscores the importance of a comprehensive and proactive approach in managing trauma in elderly patients, ensuring appropriate measures are taken to address severe complications while minimizing unnecessary procedures.

Patient consent

We confirm that we have obtained written, informed consent from the patient for the publication of this case report. The patient has been thoroughly informed about the details that will be published and understands the implications of the publication. The written consent is stored securely and is available for review by the editorial team upon request.