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Children with bleeding problems

Children with bleeding problems

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Published by helwa_husna
bleeding child, paediatric CME for HO
bleeding child, paediatric CME for HO

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Published by: helwa_husna on Feb 04, 2013
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01/17/2014

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Children With Bleeding Problems

Helwa Husna binti Katiman 16th November 2011

1

Curriculum For Mandatory Topics – Pediatrics Condition
• Knowledge and understanding:
– Know the causes of purpura and bruising. – Recognise features in the presentation which suggest serious pathology such as child abuse. – Recognise and understand the clinical manifestations of leukaemia. – Understand the hereditary basis of haemophilia and other coagulation disorders

• Skills: – Management of ITP. – Able to recognize bleeding problem in a patient with haemophilia: • Haemarthrosis • ICH . – Management of Leukemias.

org/wiki/Purpura .Introduction PETECHIAE measure less than 3 mm PURPURA measure 3–10 mm ECCHYMOSES greater than 10 mm bleeding into the skin layers from broken blood vessels red/purple spots that don't blanch on pressure http://en.wikipedia.

com/educationalTools/learnDerm/lesson1.logicalimages.Diascopy • Differentiating between a blanching erythema and non-blanching purpura by pressing with a glass slide http://www.htm 5 .

or inflammation. sunburn or waxing and tweezing of the hairs—any of which can cause the capillaries to dilate. infection. caused by hyperemia of the capillaries in the lower layers of the skin. • Blanching on pressure. electrical treatment. massage. acne medication. exercise. 6 . allergies.Erythema • Redness of the skin. • Examples of erythema not associated with pathology include nervous blushes. • It occurs with any skin injury. resulting in redness. • It can be caused by infection.

the rash is often more purpuric than petechial usually. the septicaemic rash rapidly spreads into purple bruises which usually does not fade under pressure. Meningococcal rashes • • • • • HSP non blanching rashes . It usually resolves by itself over time.Causes of Petechiae / Purpura • Meningococcal infection -bacteria multiply in the blood vessels and release toxins. It can start off as a pink or purple blood spots which are blanching on pressure (False Negative). Idiopathic thrombocytopenia purpura . The condition is caused by low platelets. joints. In the final critical stage. Enterovirus infection. including the clotting cells. It usually resolves by itself and no treatment is required.a condition that involves the skin. gut and kidneys. Leukemia . Henoch-Schonlein Purpura (HSP) .this is a cancer of the bone marrow and causes low blood cells. It may just start off with large bruises that occur easily.any infection if severe enough may interfere with the normal body clotting system . Children may also be pale and prone to infection. Severe infection .

• There are three types of bruises: – Subcutaneous -.beneath the skin – Intramuscular -. sports injuries. or blows received by other people or objects.bone bruise • Bruises are often caused by falls.within the belly of the underlying muscle – Periosteal -.Causes of Bruising @ Contusion / Ecchymoses / Hematoma • A bruise is an area of skin discoloration. car accidents. • A bruise occurs when small blood vessels break and leak their contents into the soft tissue beneath the skin. .

shiri ga aoi (尻が青い) 9 .

bruises. bites. • Has fading bruises or other marks noticeable after an absence from school. • Reports injury by a parent or another adult caregiver. •Uses harsh physical discipline with the child. Consider the possibility of physical abuse when the parent or other adult caregiver: •Offers conflicting. •Has a history of abuse as a child." or in some other very negative way. •Describes the child as "evil. or black eyes. or no explanation for the child's injury. • Shrinks at the approach of adults. unconvincing. broken bones.Recognize Child Abuse Features Signs of Physical Abuse Consider the possibility of physical abuse when the child: • Has unexplained burns. • Seems frightened of the parents and protests or cries when it is time to go home. .

11 .The child shown has a large bruise in the shape of a handprint from excessive physical punishment. The long linear streaks on this child's leg are bruising from repeated strikes by a stick. Retinal hemorrhages (black arrow) are diagnostic of shaken-baby syndrome until proven otherwise.

Child with slap mark. 12 . Sunburn. Burn inflicted with lighter.

Inflicted pinch mark shaft. Bruises inflicted with wooden spoon. 13 .Bruises inflicted with belt.

Sexual Abuse Physical examination findings: • Genital bleeding • Vaginal discharge • Anogenital bruising or redness • Unexplained difficulty walking or sitting 14 .

Illustrated Case Study A 2-year-old boy has had a swollen left knee for 1 day. he has had swelling and bruising on his left foot as well.10(11):397-401. She denies any known trauma. and change in urination or bowel movements. 15 . change in level of activity or appetite. Citation: Consultant For Pediatricians. 2011. The patient is able to bear weight and has continued his normal activities. especially around his diaper area. The mother often notices bruising. The mother reports that she noticed a bruise on the left side of his knee 2 days earlier and that her son was limping yesterday and “keeping his left leg straight” while walking. Since the morning of presentation. fever.

The patient resists passive movement of left knee and ankle. he walks with a limp. which has mild associated swelling. His weight is 12.The patient sits on his mother’s lap. and in no distress. which is warm to the touch. When prompted. Ecchymosis is noted on the lateral aspect of the left knee.7 kg. splinting the left knee joint. Hemarthrosis / hemophilic arthropathy 16 . Vital signs are normal. The left knee and thigh are enlarged compared with the right side. is calm. cooperative. and on the dorsal aspect of the left foot.

Nelson Essentials of Pediatrics . Fifth Edition 17 .

enzymeresearch.http://www.uk/coag.co.ht 18 .

. menstrual Prolonged /Normal Prolonged /Normal Muscle. surgical. surgical Normal Prolonged Normal Low Normal Normal Normal Low Recombinant IX Normal Low /Normal Low Low Normal DDAVP* or recombinant VIII DDAVP* or vWF concentrate 19 *Desmopressin (DDAVP) for mild to moderate hemophilia A or type 1 von Willebrand disease.Comparison of Hemophilia A. joint. Hemophilia B. skin. and von Willebrand Disease Hemophilia A Inheritance X-linked Hemophilia B von Willebrand Disease AD Factor deficiency Bleeding site(s) PT APTT Bleeding time Factor VIII coagulant activity vWF antigen vWF activity Factor IX Treatment Factor VIII Factor IX vWF and VIIIC Mucousa.

HAEMOPHILIA http://www.org.au/bleedingdisorders/cid/2/parent/0/pid/2/t/bleedingdisorders/title/haemophilia 20 .haemophilia.

Classification Of Haemophilia And Clinical Presentation Factor level <1% (<0. surgery. predominantly into joints & muscles. Bleeding with major trauma. surgery. invasive procedures. invasive procedures.01-0. 1-5% (0. Can bleed after minor injury. Bleeding can occur spontaneously or after minor injury.05-0. May have joint bleeding.01IU/mL) Classification Clinical presentation Frequent bleeding episodes common. Severe bleeding with trauma.05IU/mL) 5-40% (0.40IU/mL) .

Haemarthroses What happens in a joint bleed? Which joint bleeds are most common? What are the long-term effects of joint bleeds? 22 .

Intramascular Haemorrhage What happens in a muscle bleed? Which muscle bleeds are most common? What are the long-term effects of muscle bleeds? 23 .

injury. or surgery. dental injections. 24 . especially in children. • Other bleeds may be very serious. but usually not life-threatening. clumsiness. spine. confusion. • Bleeding into the throat may result from infection. vomiting. and psoas muscle. such as bleeds into the eyes. weakness. but rarely dangerous. nausea. sleepiness. as well as difficulty swallowing and breathing.Other Bleeding • Intracranial haemorrhage (ICH) is a major cause of death in hemophilia. and loss of consciousness. Head bleeds can cause headache. • Hematuria is common in severe hemophilia. fits. Throat bleeds cause swelling.

4. COMPRESSION: Joints can be wrapped in a tensor bandage or elastic stocking. REST: The arm or leg should rest on pillows or be put in a sling or bandage. ICE: Wrap an ice pack in a damp towel and put it over the bleed. . This gentle pressure may help to limit bleeding and support the joint. This may help decrease pain and limit bleeding. This may slow blood loss by lowering pressure in the area. Use compression carefully with muscle bleeds if a nerve injury is suspected. After 5 minutes. for as long as the joint feels hot. Keep alternating: 5 minutes on. 25 2. ELEVATION: Raise the area that is bleeding above the level of the heart. remove the ice for at least 10 minutes.First Aid 1. 10 minutes off. 3. The person should not move the bleeding joint or walk on it.

cryoprecipitate and factor concentrate.Treatment • Replacing the missing factor. intravenously. (FFP and cryoprecipitate have higher risk for viral transmission) • Synthetic Desmopressin or DDAVP: mild to moderate hemophilia A or type 1 von Willebrand disease It can be given by nasally. • Recombinant factors VIII and IX 26 . • Clotting factor: FFP. or as a tablet.

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