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Paramedics bring in a 7-year-old boy who fell from a play structure at school. A teacher has accompanied the patient and has the school medical records. The boy has Hemophilia A without inhibitor according to the records. The school does not have any of his Factor replacement. The boy has a large parietal hematoma, no open wounds, equal and reactive pupils, no hemotympanum or Battle sign or raccoon eyes, and a GCS of 12. The remainder of his exam is normal. Besides evaluating ABCs and performing a trauma exam, and contacting his parents and hematologist, what is your first management step?
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September 21, 2025 at 1:09 pm
D) Provide Factor VIII before the level is known
If significant bleeding is suspected in a patient with hemophilia, factor replacement should be given immediately. If the patient has his/her own factor product with them, use that. The dose for Factor VIII in this emergent situation is 50 IU/kg given IV push over 1-2 minutes (or according to package directions), which should bring the factor level to 80-100%. Factor replacement in suspected severe bleeding should be given before laboratory tests return and before radiologic or other diagnostic studies. If there were a known inhibitor, a bypass product such as recombinant factor VIIa (rFVIIa) or FEIBA might have been indicated. Guidelines for ED care of patients with hemophilia can be found at https://www.bleeding.org/healthcare-professionals/guidelines-on-care/masac-documents/masac-document-257-guidelines-for-emergency-department-management-of-individuals-with-hemophilia-and-other-bleeding-disorders.