Disorders of Disorders of HemostasisHemostasisSultana Qureshi, PGY-2Sultana Qureshi, PGY-2

Resident RoundsResident Rounds

March 1, 2007March 1, 2007

Thanks to Adam Oster for some slides!

GoalsGoals

Approach and when to be suspiciousApproach and when to be suspicious Pattern of presentationPattern of presentation ED Management – when to use blood ED Management – when to use blood

productsproducts

HemostasisHemostasis

Endothelial cellsEndothelial cells PlateletsPlatelets Blood flow & vasoconstrictorsBlood flow & vasoconstrictors Clotting cascadeClotting cascade FibrinolysisFibrinolysis

Approach to Bleeding Approach to Bleeding DisordersDisorders

Primary Primary HemostasisHemostasis Exposed Exposed

endothelial cells endothelial cells cause platelets to cause platelets to aggregate and form aggregate and form plugplug

Platelet DisordersPlatelet Disorders ITPITP TTPTTP Also partially in liver Also partially in liver

disease, vWDdisease, vWD

Secondary Secondary HemostasisHemostasis Tissue factor iniates Tissue factor iniates

coagulation cascade coagulation cascade eventually leading to eventually leading to fibrinogen forming fibrinogen forming fibrin cross linksfibrin cross links

Extrinsic starts Extrinsic starts pathway, intrinsic pathway, intrinsic sustainssustains

Coagulation DisordersCoagulation Disorders vWDvWD Hemophilia A & BHemophilia A & B Other – consumptive Other – consumptive

(DIC)(DIC)

When to be suspiciousWhen to be suspicious Petechiae, Purpura, EcchymosisPetechiae, Purpura, Ecchymosis Nature of bleeding/sitesNature of bleeding/sites Significant or multiple episodesSignificant or multiple episodes Signs of previous bleedingSigns of previous bleeding Medications (anti-coagulants)Medications (anti-coagulants) Associated disease: liver disease, sepsisAssociated disease: liver disease, sepsis Massive transfusionMassive transfusion FHxFHx Other important historical/physical Other important historical/physical

info to know???info to know???

Approach to Bleeding Approach to Bleeding DisordersDisorders

Platelet DisorderPlatelet Disorder Immediate onsetImmediate onset Superficial bleedingSuperficial bleeding

Petechiae/Ecchymoses Petechiae/Ecchymoses (mucocutaneous)(mucocutaneous) GI/GU bleedingGI/GU bleeding Menorrhagia, Menorrhagia,

epistaxis, melenaepistaxis, melena

Plt or Bleeding Time Plt or Bleeding Time abnabn

PT/PTT NPT/PTT N

Coagulation Factor Coagulation Factor DisorderDisorder

Delayed onset Delayed onset (hours/days)(hours/days)

Deep bleedingDeep bleeding IntramuscularIntramuscular IntraarticularIntraarticular RetroperitonealRetroperitoneal HematuriaHematuria Hemarthrosis/hematomasHemarthrosis/hematomas

Less common to have Less common to have menorrhagia, epistaxis, menorrhagia, epistaxis, etc etc

Plt and BT NPlt and BT N PT/PTT abnPT/PTT abn

LabsLabs CBC, pltsCBC, plts PTT (intrinsic) – I, II, V, VII, IX, X, XI, XIIPTT (intrinsic) – I, II, V, VII, IX, X, XI, XII INR (extrinsic)– I , II, V, VII, XINR (extrinsic)– I , II, V, VII, X Peripheral smearPeripheral smear FibrinogenFibrinogen D-dimerD-dimer FDPFDP Factor levelsFactor levels Thrombin timeThrombin time

What and how do you measure What and how do you measure bleeding time?bleeding time?

When is it useful?When is it useful?

Blood ProductsBlood Products

Platelets – 1 unit raise value by 5-10Platelets – 1 unit raise value by 5-10 Cryoprecipitate – FVIII, vWF, Cryoprecipitate – FVIII, vWF,

fibrinogen, fibronectinfibrinogen, fibronectin FFP – contains all coagulation FFP – contains all coagulation

factors (about 7% of a 70kg person)factors (about 7% of a 70kg person)

CaseCase

25F – 32 wks GA presents with decr. 25F – 32 wks GA presents with decr. LOCLOC

Husband states had intermittent abdo Husband states had intermittent abdo pain X 2 days, suddenly got worse pain X 2 days, suddenly got worse todaytoday

Vitals: 120, 90/50, 18, 99% 2L NP, Vitals: 120, 90/50, 18, 99% 2L NP, 36.536.5

Doppler – fetal bradycardiaDoppler – fetal bradycardia Uterus is tender and tense Uterus is tender and tense

DIC - CausesDIC - Causes••  Sepsis/severe infectionSepsis/severe infection

(any microorganism)(any microorganism)

••  TraumaTrauma (eg, polytrauma, (eg, polytrauma, neurotrauma, fat embolism)neurotrauma, fat embolism)

••  Organ destruction (eg,severe Organ destruction (eg,severe pancreatitis)pancreatitis)

••  Malignancy Malignancy ––solid tumorssolid tumors–myeloproliferative/ –myeloproliferative/ lymphoproliferativelymphoproliferative

••  Obstetrical calamitiesObstetrical calamities ––amniotic fluid embolismamniotic fluid embolism–abruptio placentae–abruptio placentae

••  Vascular abnormalities Vascular abnormalities ––Kasabach-Merritt Kasabach-Merritt SyndromeSyndrome–large vascular aneurysms–large vascular aneurysms

••  Severe hepatic failureSevere hepatic failure

••  Severe toxic or Severe toxic or immunologic reactions immunologic reactions

––snake bitessnake bites–recreational drugs–recreational drugs–transfusion reactions–transfusion reactions–transplant rejection–transplant rejection

HypothermiaHypothermia AcidosisAcidosis

PathophysiologyPathophysiology Unifying cause relates to widespread endothelial Unifying cause relates to widespread endothelial

damage with extensive cytokine releasedamage with extensive cytokine release DIC is a spectrum, may have thrombosis or bleeding DIC is a spectrum, may have thrombosis or bleeding

or bothor both Activation of procoagulant pathwayActivation of procoagulant pathway

Hemolysis, tissue injury, malignancy, fat embolism, heat strokeHemolysis, tissue injury, malignancy, fat embolism, heat stroke Endothelial damageEndothelial damage

Sepsis, vasculitis, aneurysm, hemangiomaSepsis, vasculitis, aneurysm, hemangioma Reticuloendothelial injuryReticuloendothelial injury

Liver disease, splenectomyLiver disease, splenectomy Vascular stasisVascular stasis

Hypotension, hypovolemia, PEHypotension, hypovolemia, PE OtherOther

Acute hypoxia/acidosisAcute hypoxia/acidosis

Clinical FeaturesClinical Features Signs of Microvascular Signs of Microvascular

Thrombosis (10-40%)Thrombosis (10-40%) NeuroNeuro

Multifocal, delirium, Multifocal, delirium, coma, seizurescoma, seizures

SkinSkin Focal ischemia, superficial Focal ischemia, superficial

gangrenegangrene RenalRenal

Oliguria, azotemia, Oliguria, azotemia, cortical necrosiscortical necrosis

PulmonaryPulmonary ARDSARDS

GIGI Acute ulcerationAcute ulceration

RBCRBC Microangiopathic Microangiopathic

hemolysishemolysis

Signs of Signs of hemorrhagic hemorrhagic diasthesis (more diasthesis (more common)common) NeuroNeuro

IC bleedIC bleed SkinSkin

Petechiae, echymosis, Petechiae, echymosis, oozingoozing

RenalRenal hematuriahematuria

MucosalMucosal Gingival oozing, Gingival oozing,

epistaxis, massive epistaxis, massive bleedbleed

LabsLabs

Consumptive CoagulopathyConsumptive Coagulopathy ↓↓PltsPlts ↑↑PT, ↑PTTPT, ↑PTT ↓↓Fibrinogen (careful in sepsis)Fibrinogen (careful in sepsis) +D-dimer (DIC)+D-dimer (DIC)

DIC Scoring SystemDIC Scoring System Step 1.Step 1.  Risk assessment: does the patient have an underlying disorder Risk assessment: does the patient have an underlying disorder

known to be associated with overt DIC? If yes, proceed. If no, do not use known to be associated with overt DIC? If yes, proceed. If no, do not use this algorithm.this algorithm.

Step 2Step 2.. Order global coagulation tests: platelet count, prothrombin time  Order global coagulation tests: platelet count, prothrombin time (PT), fibrinogen, soluble fibrin monomers, or fibrin degradation products.(PT), fibrinogen, soluble fibrin monomers, or fibrin degradation products.

Step 3.Step 3.  Score global coagulation test results: Score global coagulation test results: ••  platelet count (> 100 = 0, < 100 = 1, < 50 = 2)platelet count (> 100 = 0, < 100 = 1, < 50 = 2)

•• elevated fibrin-related marker (eg, soluble fibrin monomers/fibrin  elevated fibrin-related marker (eg, soluble fibrin monomers/fibrin degradation products) no increase: 0; moderate increase: 2; strong degradation products) no increase: 0; moderate increase: 2; strong increase: 3*increase: 3*•• prolonged prothrombin time (< 3 sec. = 0, > 3 but < 6 sec = 1, > 6 sec  prolonged prothrombin time (< 3 sec. = 0, > 3 but < 6 sec = 1, > 6 sec = 2)= 2)•• fibrinogen level (> 1.0 g/L = 0, < 1.0 g/L = 1) fibrinogen level (> 1.0 g/L = 0, < 1.0 g/L = 1)

Step 4.Step 4. Calculate score. Calculate score.

Step 5.Step 5. If ≥5: compatible with overt DIC; repeat scoring daily. If <5:  If ≥5: compatible with overt DIC; repeat scoring daily. If <5: suggestive (not affirmative) for non-overt DIC; repeat next 1–2 days.suggestive (not affirmative) for non-overt DIC; repeat next 1–2 days.

* In the prospective validation studies, D-dimer assays were used and a * In the prospective validation studies, D-dimer assays were used and a value above the upper limit of normal was considered moderately value above the upper limit of normal was considered moderately elevated; whereas, a value above five times the upper limit of normal was elevated; whereas, a value above five times the upper limit of normal was considered a strong increase.considered a strong increase.

Bakhtiari K et al. Critical Care Med. 2004;32:2416-2421.

DIC Scoring SystemDIC Scoring System

Sens 93%Sens 93% Spec 96%Spec 96%

Bakhtiari K et al. Critical Care Med. 2004;32:2416-2421.

ManagementManagement TREAT UNDERLYING CAUSE!!!TREAT UNDERLYING CAUSE!!! Blood ProductsBlood Products Only if active bleeding or high risk of Only if active bleeding or high risk of

bleeding (ie. early post op or pre-invasive bleeding (ie. early post op or pre-invasive procedure) procedure) PlateletsPlatelets

Bleeding – tranfuse if count <50Bleeding – tranfuse if count <50 No bleeding – transfuse if <10-20No bleeding – transfuse if <10-20

FFPFFP CryoprecipitateCryoprecipitate

If fibrinogen <2If fibrinogen <2 1-4U/10 kg1-4U/10 kg

Novel treatmentsNovel treatments

APC – up to Phase III trials show APC – up to Phase III trials show benefit in septic DICbenefit in septic DIC

TFPI – promisingTFPI – promising ATIII- RCT promisingATIII- RCT promising HeparinHeparin

Only case series. ControversialOnly case series. Controversial Therapeutically if overt venous TE or Therapeutically if overt venous TE or

purpura fulminanspurpura fulminans

CaseCase 22M presents with seizures, decr. LOC, 22M presents with seizures, decr. LOC,

jaundice and feverjaundice and fever Purpuric rash over bodyPurpuric rash over body V: 60, 110/70, 16, 96% RA, T=38.3V: 60, 110/70, 16, 96% RA, T=38.3 Hb 90, WBC 8.0, plt 20Hb 90, WBC 8.0, plt 20 PT/PTT N PT/PTT N Cr 130, small hematuriaCr 130, small hematuria T.bili 60 other LFTs N, LDH 500T.bili 60 other LFTs N, LDH 500 Ddx?Ddx? D-dimer/fibrinogen?D-dimer/fibrinogen?

TTPTTP

Main ED mgmt point:Main ED mgmt point: NO platelet transfusion unless life NO platelet transfusion unless life

threatening hemorrhagethreatening hemorrhage

Liver DiseaseLiver Disease

What mechanisms of coagulopathy?What mechanisms of coagulopathy? What blood products to use?What blood products to use?

Liver DiseaseLiver Disease Why they bleed?Why they bleed?

Thrombocytopenia from hypersplenism (portal Thrombocytopenia from hypersplenism (portal HTN)HTN)

Platelet dysfunctionPlatelet dysfunction Reduction in absorption of Vit K dependant Reduction in absorption of Vit K dependant

factors (2, 7, 9, 10)factors (2, 7, 9, 10) Reduction in synthesis of most factors Reduction in synthesis of most factors Dysfibrinogenemia (abn fibrinogen synthesis)Dysfibrinogenemia (abn fibrinogen synthesis) Enhanced fibrinolysis (decr. Plasmin inhibitor)Enhanced fibrinolysis (decr. Plasmin inhibitor) In bleeding ER – may require transfusion of In bleeding ER – may require transfusion of

many different products (RBC, plts, FFP, cryo)many different products (RBC, plts, FFP, cryo) Vs. DIC???Vs. DIC???

CaseCase

6F with epistaxis (has had multiple mild 6F with epistaxis (has had multiple mild episodes in past 2d)episodes in past 2d)

Also history of spitting up blood in morningAlso history of spitting up blood in morning Examine mouth and see blood oozing from Examine mouth and see blood oozing from

gums when scraped with tongue depressorgums when scraped with tongue depressor Otherwise well other than flu 3 weeks agoOtherwise well other than flu 3 weeks ago Notice petechiae around sock elasticNotice petechiae around sock elastic Dx?Dx? Lab results?Lab results?

Acute ITPAcute ITP Usually children 2-6Usually children 2-6 M=FM=F Usually have had recent infectionUsually have had recent infection Abrupt onset of bleeding (vs insidious)Abrupt onset of bleeding (vs insidious) Platelets <20Platelets <20 Usually lasts weekUsually lasts week 80% spontaneous remission80% spontaneous remission Management: IVIG if bleeding significant Management: IVIG if bleeding significant

of plts <10of plts <10 -splenectomy in very -splenectomy in very severe casessevere cases

Chronic ITPChronic ITP MCC of isolated thrombocytopeniaMCC of isolated thrombocytopenia Adults (20-40 yo), F>M (3:1)Adults (20-40 yo), F>M (3:1) No precipitating infectionNo precipitating infection Insidious bleeding (heavy periods, easy Insidious bleeding (heavy periods, easy

bruising)bruising) Plt 30-80Plt 30-80 May last months to years, and uncommon May last months to years, and uncommon

spont. Remissionspont. Remission Mgmt: steroids, IVIG, splenectomyMgmt: steroids, IVIG, splenectomy Need w/u for other causes of Need w/u for other causes of

thrombocytopenia! Esp if older (ie thrombocytopenia! Esp if older (ie malignancy)- Smearmalignancy)- Smear

Major concern is cerebral hemorrhage is Major concern is cerebral hemorrhage is plt<5plt<5

Platelet DisordersPlatelet Disorders

DestructionDecreased Production

Sequestration

Immune Non-immune

ITP TTPDICHELLPSepsis

splenomegaly

Marrow failure

Quantitative Qualitative

ASA, plavixrena and hepatic disease,vWD

CaseCase

12F hx of VWD12F hx of VWD Presents with heavy menarche Presents with heavy menarche

(ongoing bleeding for >7 days)(ongoing bleeding for >7 days) Pale, asymptomaticPale, asymptomatic Hb = 60Hb = 60 Mgmt?Mgmt?

Erik Adolf von Erik Adolf von Willebrand Willebrand

1870-19491870-1949 Finnish Finnish

PediatricianPediatrician ““known for known for

integrity and integrity and modesty”modesty”

Hjordis – 5 yo girl Hjordis – 5 yo girl with FHx of with FHx of bleeding disordersbleeding disorders

Von Willebrand’s DiseaseVon Willebrand’s Disease

ADAD Qualitative vs. quantitative abnQualitative vs. quantitative abn Different sized multimersDifferent sized multimers vWF has 2 jobs vWF has 2 jobs

Platelet adhesion, carrier for Factor VIII Platelet adhesion, carrier for Factor VIII New ClassificationNew Classification

Type 1: mild quantitative defect (75%)Type 1: mild quantitative defect (75%) Type 2: qualitative defect (impaired fxn)20%Type 2: qualitative defect (impaired fxn)20% Type 3: severe total quantitative defect (rare)Type 3: severe total quantitative defect (rare)

ManagementManagement

Type 1Type 1 Usually mild symptoms (mucocutaneous Usually mild symptoms (mucocutaneous

bleeding sources)bleeding sources) Mgmt: DDAVP 0.2 mcg/kg IV/IM/INMgmt: DDAVP 0.2 mcg/kg IV/IM/IN

Type 2 or 3Type 2 or 3 More likely to have mod-severe symptoms More likely to have mod-severe symptoms

incl. soft tissue hematomas, GI bleeds, incl. soft tissue hematomas, GI bleeds, hemarthroseshemarthroses

Mgmt: Cryoprecipitate +/- DDAVP +/- Mgmt: Cryoprecipitate +/- DDAVP +/- Humate PHumate P

CaseCase

50M slipped on ice and twisted R 50M slipped on ice and twisted R kneeknee

On exam: large hemarthrosisOn exam: large hemarthrosis What is most likely hemostatic What is most likely hemostatic

disorder?disorder? Management?Management?

HemophiliaHemophilia

A – FVIII deficiencyA – FVIII deficiency B – FIX deficiencyB – FIX deficiency X-linked recessiveX-linked recessive Mild/mod/severe is based on factor activityMild/mod/severe is based on factor activity

5-30%, 1-5%, <1% 5-30%, 1-5%, <1% PTT prolonged (if factor activity <30%) PT PTT prolonged (if factor activity <30%) PT

NN However, if mild hemophilia, PTT may be However, if mild hemophilia, PTT may be

NN

Bleeding first noticed usually in Bleeding first noticed usually in early yearsearly years

5 Hs:5 Hs: HemarthrosesHemarthroses HematomasHematomas HematocheziaHematochezia HematuriaHematuria Head hemmorhageHead hemmorhage

Recurrent hemarthroses lead to joint damageRecurrent hemarthroses lead to joint damage IC bleed is major cause of deathIC bleed is major cause of death Also, tend to bleed LATE – days after minor injuryAlso, tend to bleed LATE – days after minor injury Therefore treat aggressivelyTherefore treat aggressively

Goal to achieve 30-100% factor activityGoal to achieve 30-100% factor activity Options: Specific factor replacement, cryo, FFPOptions: Specific factor replacement, cryo, FFP Consider: Severity of bleeding, disease severity Consider: Severity of bleeding, disease severity

and availability of productsand availability of products Always consider factor activity is zero in ED!!!Always consider factor activity is zero in ED!!!

Factor ReplacementFactor Replacement

Is ideal if available in ED, otherwise cryoIs ideal if available in ED, otherwise cryo 1U/kg will increase factor by 2%1U/kg will increase factor by 2% May develop alloantibodies and need 3-May develop alloantibodies and need 3-

4X predicted dose4X predicted dose Goals:Goals:

Mild: 5-10% activity desired -initial dose Mild: 5-10% activity desired -initial dose 12.5U/kg12.5U/kg

Mod 20-30% - 25U/kgMod 20-30% - 25U/kg Severe >50% - 50U/kgSevere >50% - 50U/kg

CryoprecipitateCryoprecipitate

Contains 80- 100U FVIII Contains 80- 100U FVIII (als contains vWF, (als contains vWF, fibrinogen, FXIII and fibronectin)fibrinogen, FXIII and fibronectin)

Considered a second line agent for Considered a second line agent for Hem AHem A

Dose = 2bags/10kg to raise FVIII to Dose = 2bags/10kg to raise FVIII to hemostatic levelshemostatic levels

T ½ = 8hrsT ½ = 8hrs

FFPFFP

Fluid portion of blood separated at Fluid portion of blood separated at 18C then frozen18C then frozen

Contains all coagulation factorsContains all coagulation factors Approx 7% of of all coag factor activity Approx 7% of of all coag factor activity

of a 70kg personof a 70kg person Not routinely used as factor Not routinely used as factor

replacement in Hem Areplacement in Hem A Could consider if nothing else availableCould consider if nothing else available

CaseCase

25M hemophiliac25M hemophiliac Tripped on stairs and fell from 1ft Tripped on stairs and fell from 1ft

heightheight Hit head on floor. No LOC, NV. Feels Hit head on floor. No LOC, NV. Feels

finefine Management?Management?

MgmtMgmt

All hemophiliacs with any trauma All hemophiliacs with any trauma need admission for observationneed admission for observation

Minor head trauma can be life Minor head trauma can be life threateningthreatening Give Factor VIII to 50% activity Give Factor VIII to 50% activity

BEFORE CTBEFORE CT

Take Home PointsTake Home Points

Approach to bleeding disordersApproach to bleeding disorders High index of suspicionHigh index of suspicion

Difference in presentation of platelet Difference in presentation of platelet dysfunction vs. coagulation factor dysfunction vs. coagulation factor d/od/o

When to give blood products?When to give blood products?

Take Home PointsTake Home Points

DIC – treat underlying causeDIC – treat underlying cause

vWF – important to know typevWF – important to know type

Hemophilia – aggressive therapy Hemophilia – aggressive therapy with factorswith factors

QuizQuiz

Which of the following is least likely Which of the following is least likely due to a platelet disorder?due to a platelet disorder? A) EpistaxisA) Epistaxis B) Retroperitoneal BleedingB) Retroperitoneal Bleeding C) EcchymosesC) Ecchymoses D) PetechiaeD) Petechiae

QuizQuiz

Which is least likely associated with Which is least likely associated with coagulation factor deficiency?coagulation factor deficiency? A) Intra-articular bleedingA) Intra-articular bleeding B) Delayed bleedingB) Delayed bleeding C) Retroperitoneal BleedingC) Retroperitoneal Bleeding D) PetechiaeD) Petechiae

QuizQuiz

Which clinical finding is MOST Which clinical finding is MOST COMMONLY associated with the COMMONLY associated with the onset of ITP?onset of ITP? A) EcchymosesA) Ecchymoses B) PurpuraB) Purpura C) PetechiaeC) Petechiae D) Gingival bleedingD) Gingival bleeding

QuizQuiz

Which of the following are true of Which of the following are true of chronic ITP?chronic ITP? A) More likely in female childrenA) More likely in female children B) Spontaneous remission typicalB) Spontaneous remission typical C) Underlying disorder is autoimmuneC) Underlying disorder is autoimmune D) Platelet transfusion is initial, D) Platelet transfusion is initial,

definitive therapydefinitive therapy

QuizQuiz

Which lab finding is more indicative Which lab finding is more indicative of liver disease vs DIC?of liver disease vs DIC? A) Thrombocytopenia with bleedingA) Thrombocytopenia with bleeding B) Prolonged PTB) Prolonged PT C) Decreased fibrinogenC) Decreased fibrinogen D) Normal or min. elevated D-dimerD) Normal or min. elevated D-dimer

QuizQuiz

50M cirrhotic with ascites presents with 50M cirrhotic with ascites presents with SBP.SBP.

HD stable and no active bleedingHD stable and no active bleeding Prolonged PTT, INRProlonged PTT, INR Low platelets and fibrinogenLow platelets and fibrinogen What to give prior to paracentesis?What to give prior to paracentesis?

A) CryoA) Cryo B)FFPB)FFP C)PlateletsC)Platelets D)DDAVPD)DDAVP

QuizQuiz

Most commonly observed lab Most commonly observed lab abnormality in DIC?abnormality in DIC? A) Long PTTA) Long PTT B) ThrombocytopeniaB) Thrombocytopenia C) Low fibrinogenC) Low fibrinogen D) elevated D-dimerD) elevated D-dimer

QuizQuiz

What is the most appropriate What is the most appropriate analgesic for a patient with Type 1 analgesic for a patient with Type 1 vWD?vWD? 1) ASA 801) ASA 80 2) ASA 3252) ASA 325 3) Ibuprofen3) Ibuprofen 4) Acetaminophen4) Acetaminophen 5) Naprosyn5) Naprosyn

QuizQuiz

9M with Type 1 vWD presents with 9M with Type 1 vWD presents with mild gingival bleeding after flossing. mild gingival bleeding after flossing.

Stable, however slow bleeding has Stable, however slow bleeding has continued for hours despite local continued for hours despite local pressurepressure

Most appropriate treatment?Most appropriate treatment?

QuizQuiz

19M restrained back seat passenger, 19M restrained back seat passenger, rear ended at 35 kph. Hit head on rear ended at 35 kph. Hit head on front seatback. No LOC. No neck front seatback. No LOC. No neck pain. Ambulatory on scene.pain. Ambulatory on scene.

Exam normal except small contusion Exam normal except small contusion to forehead.to forehead.

History of Hemophilia BHistory of Hemophilia B Mgmt?Mgmt?

QuizQuiz 7M presents with LLQ pain after being 7M presents with LLQ pain after being

“knee’ed” by a bully at school 2 hours ago“knee’ed” by a bully at school 2 hours ago History of Hemophilia A “severe”History of Hemophilia A “severe” VSS, contusion in L inguinal area, mildly VSS, contusion in L inguinal area, mildly

tendertender Pain with extension of lower extremity, Pain with extension of lower extremity,

and walks flexed at the torso with a limpand walks flexed at the torso with a limp Next step?Next step?

A) Give Factor VIII and CT AbdoA) Give Factor VIII and CT Abdo B) Give Factor IX and CT AbdoB) Give Factor IX and CT Abdo C) Give DDAVP and CTC) Give DDAVP and CT D) Give FFP and US AbdoD) Give FFP and US Abdo