🩸 Chapter 114: Approach to a Bleeding Child

Platelet vs coagulation disorders · PT, aPTT, INR, fibrinogen, D-dimer · Platelet transfusion thresholds · DIC · HIT · Vitamin K deficiency · Haemophilia A/B · von Willebrand disease · Mixing studies · rFVIIa

🔍 Core Concepts: Approach to Bleeding Child

📌 Platelet vs Coagulation Disorders
Platelet: superficial bleeding (petechiae, ecchymosis, mucosal). Coagulation: deep bleeding (haemarthrosis, muscle haematoma, delayed bleeding).
🧪 Initial Labs
CBC, PT, aPTT, INR, fibrinogen, D-dimer, peripheral smear. Mixing studies: corrects with normal plasma = factor deficiency; no correction = inhibitor.
💊 Platelet Transfusion Thresholds
<10k (asymptomatic), <20k (fever/sepsis), <50k (invasive procedure), <100k (ECMO/neurosurgery). Transfuse 5-10 mL/kg.
🩸 DIC Management
Treat underlying cause. Transfuse if bleeding: platelets (<50k), FFP (10-15 mL/kg), cryoprecipitate (fibrinogen <100).
⚠️ HIT (Heparin-Induced Thrombocytopenia)
Platelet drop >50% 5-10 days after heparin. Stop all heparin. Use direct thrombin inhibitor (argatroban, lepirudin).
🧬 Haemophilia A/B & vWD
Haemophilia A (factor VIII deficiency): isolated prolonged aPTT. vWD: prolonged bleeding time, normal PT/aPTT (may have low factor VIII).

🩺 Stepwise Approach: Bleeding Child

1
Resuscitate & identify source
ABCs, IV access, fluid bolus if haemodynamically unstable. Identify surgical bleeding (control with pressure/ligation).
2
Initial labs & bleeding pattern
PT, aPTT, INR, fibrinogen, D-dimer, CBC, platelet count, peripheral smear. Distinguish platelet vs coagulation disorder.
3
Interpret coagulation profile
Prolonged PT only: factor VII deficiency, early vitamin K deficiency, warfarin. Prolonged aPTT only: haemophilia, vWD, lupus anticoagulant. Both prolonged: DIC, liver disease, late vitamin K deficiency.
4
Platelet transfusion (if indicated)
Threshold: <10k asymptomatic, <20k with fever/sepsis, <50k before invasive procedure, <100k for ECMO/neurosurgery.
5
DIC management
Treat underlying sepsis. If bleeding: platelets (goal >50k), FFP (10-15 mL/kg), cryoprecipitate (if fibrinogen <100 mg/dL).
6
Specific therapies
Haemophilia A: factor VIII concentrate (or DDAVP for mild). Haemophilia B: factor IX. vWD: DDAVP (type I) or vWF concentrate. HIT: stop heparin, argatroban. Vitamin K deficiency: vitamin K 0.3 mg/kg + FFP if bleeding.