Emergency Department Clinical Pathway for Evaluation/Treatment
of Children with Hemophilia and Closed Head Injury (CHI)

Goals and Metrics
Patient Education
Provider Resources
Related Pathway
Triaging Child with Hemophilia and Head Trauma
Guidance for Outpatient Providers for Home Treatment, ED Referral
Goal
  • Patients with factor level < 1% who are not on emicizumab are at highest risk.
  • Give factor correction as soon as able, ideally < 1 hr.
  • Use patient’s home supply.
  • Hematology will order more factor for family.
  • Emicizumab (Hemlibra) interferes with standard clotting assays. Do NOT send PT/PTT or FVIII activity. Discuss with Hematology.
  • Head Trauma Categorization
  • Trivial - Does not require treatment or ED referral
    • Hit lightly on the head by a toy
    • Mild bump against an object
  • Mild
    • Fall from own height
    • Fall from height < 3 ft
  • Significant
    • Fall down stairs
    • Unwitnessed fall
    • MVC with head trauma
    • Fall from height > 3 ft
    • Associated neurologic symptoms:
      • LOC, headache, nausea, emesis
Determine
  • Mechanism of injury
  • Factor level at the time of injury
  • If on emicizumab (Hemlibra®) treat like mild hemophilia
Factor level < 1%
AND mild or significant head injury
Factor level > 1% OR on emicizumab
AND significant head injury
 
 
 
 
Immediate 100% correction if family able, refer to CHOP ED
 
 
Child with Hemophilia and Head Trauma Arrives to ED
 
 
ED Triage
 
 

FLOC Team Assessment
(History & Physical)

 
 
 
 
Stable Patient
 
 
 
 
 
 
No Active Inhibitor
No/inadequate home correction
Active Inhibitor
No/inadequate home correction
Received Home Correction
  • Use patient’s home supply
    (if available)
  • Immediate MD Order for Bypassing Agent
    • NovoSeven® 90 mcg/kg OR FEIBA* 75 units/kg
  • *FEIBA is contraindicated if patient is on emicizumab (Hemlibra)
 
 
 
 
 
 
Head CT and Hematology Consultation
 
 
 
 
Admission Criteria
  • Abnormal Head CT
  • Focal exam
  • Persistent symptoms
  • Significant head trauma -
    See Head Trauma Categorization listed above
  • Patients admitted should receive additional factor correction.
Discharge Criteria
  • Normal head CT
  • Asymptomatic
  • Mild mechanism
  • Ability of family to do follow-up care
  •  
  • If used patient’s home supply, Hemophilia Team will order replacement factor
Posted: August 2005
Last Revised: November 2024
Authors: R. Butler; L. Raffini MD; C. Witmer MD; C. Jacobstein MD; J. Lavelle MD