Bleeding

Includes:

• Emergency treatment
• Causes
• Bleeding into joints
• Gastrointestinal bleeding

Emergency Treatment

• Secure airway, breathing and circulation. Urgent cross-match and transfusion (whole blood is preferable). Consider emergency transfusion of uncrossmatched O negative blood if life-threatening bleed
• If there is an obvious bleeding point apply pressure. If epistaxis use vaseline gauze with adrenaline, if anal polyp use paraffin gauze
• If septic/ unwell, commence broad spectrum antibiotics.
• If jaundiced and bleeding, give IV Vitamin K 1 - 10 mg ONLY IV (give slowly) to cover for liver failure
• IM injections should not be given to a child with a bleeding problem

Causes

Bleeding from mucous membranes or into skin (mouth, gums, nose, petechiae, very heavy menstrual bleeding) usually indicates platelet problem (deficiency or dysfunction)

Causes in 4 broad categories

• Immune mediated platelet problems e.g. Idiopathic Thrombocytopaenia Purpura (ITP) or autoimmune thrombocytopaenia in HIV or drugs
• Thrombocytopaenia as part of a general pancytopaenia e.g. bone marrow infiltration by tumour, or aplastic anaemia secondary to parvovirus B19
• Hypersplenism (e.g. tropical splenomegaly syndrome)
• DIC as part of 'sepsis' inflammatory response (e.g. meningococcaemia)

Important points in history

• Anaemia, transfusion, repeated infections (suggesting pancytopaenia)
• History of previous viral infection (suggesting ITP/ aplastic anaemia)
• History of malaise, lymphadenopathy, masses suggesting malignancy
• History compatible with HIV/ AIDS

Important points on examination

• Site and extent of petechiae, purpura and bruising
• Fever, pallor (suggests a pancytopaenia/ sepsis)
• Hepatosplenomegaly, Lymphadenopathy
• Signs consistent with HIV/ AIDS (KS lesions)

Investigations

• FBC and thin film reviewed by department lab/ haematologist if available
• Blood culture
• pancytopaenic or suspicious thin film: bone marrow aspirate may be helpful. Discuss with seniors
• HIV test

Treatment

• Cover with broad spectrum antibiotics whilst awaiting results
• If history/ examination compatible with malignancy, or if diagnosis is not clear cut, discuss with the oncology team / haematologist
• If history/ examination compatible with ITP, may be possible to watch and wait (monitoring the platelet count). In our setting HIV commonly causes autoimmune thrombocytopenia. Prednisolone 2 mg/kg PO should be given
• Give platelets (1 unit) if active bleeding and platelets < 20 x10*9/L
• FFP (10mls/kg) may be helpful if DIC

Bleeding into joints

Suggest clotting factor deficiency. Children present with acutely swollen joints following minimal trauma

Causes

• Haemophilia
• Rarely Vitamin K deficiency secondary to liver disease

Important points in history

• Prior big bleeds from small wounds (requiring transfusions?)
• Other involved family members (male? - suggesting haemophilia)

Important points on examination

• Distribution of joints involved
• Evidence of prior joint damage: e.g. restricted movement, contractures etc.

Investigations

• Clotting screen if available (esp. INR and PTT/aPTT - sometimes available via John's Hopkins Lab)
• X ray of chronically affected joints

Treatment

• Analgesia (but do not use NSAIDs, Pain management) and splinting of the joint
• If jaundiced and bleeding, give IV Vitamin K 1 - 10 mg ONLY IV (give slowly) to cover for liver failure
• Haemophilia
• Factor 8 deficiency:
• Cryoprecipitate 1/4 unit per kg x 2 days. Cryoprecipitate is OFTEN available from Malawi Blood Transfusion Service.
• FFP (10mls/Kg) if no cryoprecipitate available

Gastrointestinal Bleeding

Usually due to GI tract pathology e.g. oesophageal varices secondary to portal hypertension/liver disease, Meckel's diverticulum, stress ulcer It may be exacerbated by problems with platelets or clotting

Important Points in history

• Appearance of vomit/ stools. Blood in the vomit indicates a high intestinal/ gastric lesion. A dark tar like stool (malaena) indicates a high intestinal/ gastric lesion. Fresh blood in the stool indicates a low intestinal lesion
• If blood in the stool is it mixed with the stool (suggesting inflammation/ infection) or surrounding the stool (suggesting fissure/ polyp)
• History of liver disease as a neonate or child and portal hypertension (ascites, jaundice, haemorrhoids,) suggesting oesophageal varices

Important point on examination

• Abdominal masses, tenderness, guarding
• Ascites, jaundice, haemorrhoids, hepatomegaly, splenomegaly (suggests portal hypertension) or caput medusa
• mouth ulcers, anal fissures (suggests inflammatory bowel disease)
• Fever (suggests infection or inflammation)

Investigations

• Stool examination
• FBC and or PCV
• Abdominal USS
• Barium enema or swallow after discussion with surgeons!
• Endoscopy after discussion with surgeons!

Treatment

• Obtain IV access with a large bore cannula and transfuse if necessary
• If history/ examination suggests surgical cause (e.g. ulcer, polyp, etc) discuss with surgeons as soon as possible. The child may need urgent endoscopy
• Omeprazole or other PPI 20mg OD
• Consider Helicobacter pylori treatment if suspected ulcer