History Taking and Assessment of a Bleed

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History Taking and Assessment of a Bleed

• Regina B. Butler, RN
• The Childrens Hospital of Philadelphia
• Philadelphia, Pennsylvania USA

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History and Assessment

• Accurate and detailed history and assessment of
  bleeding episodes and trauma in individuals with
  bleeding disorders is essential for determining
  appropriate care
• The process is continuous from first notification
  of event to follow-up

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History and Assessment

• Careful documentation is essential for each step
  of the process to ensure appropriate care and
  follow-up

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The 5 History and Assessment Questions

• What are the symptoms?
• How long have the symptoms been present?
• What treatment was given?
• Did an injury happen before the symptoms started?
• Did a similar problem occur in the past?

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Assessing Potential Bleeding Episodes

• Early and appropriate treatment of each episode
  is critical
• Replacement of the deficient clotting factor is
  the single most important step in any
  intervention
• For serious bleeds, Treat First Evaluate Second

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Evaluation of Patient

• Clinical Scenario
• Patient comes to clinic/ED with bleed
• Observe patient
• Waiting area
• Walking to treatment/evaluation room (does the
  patient limp?)
• Getting onto the exam table
• Get the details of trauma, are they consistent
  with the clinical picture

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Waiting Area Assessment
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Initial Assessment

• How does he look as you see him in the waiting
  room?
• Does he appear to be in distress?
• Does he answer questions appropriately?
• Is his demeanor the same as usual?

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Assessment of Gait

• Is he limping?
• Do his complaints match his actions?
• What does he do when he thinks you arent
  watching?

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What is he doing when he doesnt know you are
watching?
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Discreet Assessment

• Does he run?
• Does he jump up to the examining table?
• Does he move his limbs normally?

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Questions to Ask

• Ask detailed questions about actions that had
  been taken at home
• Immoblization
• Ice
• Treatment
• Product
• Dose
• Frequency
• Timing

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Head Trauma

• Treat and evaluate ALL reports of head trauma

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Head Trauma

• Questions to ask
• How did he bump his head?
• Did he cry?
• How far did he fall? (degree of impact)
• Surface of impact?
• Headache?
• Loss of consciousness?

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Lack of bruising or hematoma is NOT reassuring!
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Careful Assessment for Other Head Trauma
Complications
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Other Considerations

• Evaluate for possible fractures of orbit, cheek,
  skull, if clinically indicated.
• Ophthalmologic evaluation if eye is involved.
• Evaluate social situation if injury appears
  questionable.

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Assessment of patient with signs of increased
intracranial pressure

• Always assume bleeding first, then evaluate for
  other causes.
• Headache, n/v, lethargy May be flu
• Family members may also be symptomatic.
• Treat first to cover to 100.
• Rule out CNS hemorrhage
• Then, treat symptoms

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Neck or Throat Bleeding

• Assess airway
• Treat as a serious bleed
• Prevention
• Factor coverage prior to dental procedures
• Avoid mandibular block if possible

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GI Bleeding History

• History of nose or mouth bleeding
• ASA?
• NSAIDS?
• Alcohol use?
• Treatment
• Timing
• Dose

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Assessment of GI Bleeding

• Signs
• Coffee grounds emesis
• Black, tarry stools
• Pallor
• Decreased Hb

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GI Bleeding

• Risk of significant blood loss
• Careful, serial monitoring of Hb levels important
• Investigate cause
• Teach patients signs to observe
• Follow up blood counts after resolution Need
  for iron replacement?

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Hemarthrosis

• History
• Known injury?
• Trauma?
• May need imaging to rule out fracture/ other
  orthopaedic injury
• Duration of symptoms?
• Recent bleeding in joint?
• Recent activities?

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Hemarthrosis

• History (contd.)
• Target joint?
• Previous treatment?
• Prophylaxis?
• Breakthrough bleeding may indicate inhibitor or
  inadequate dose/regimen

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Assessment of Hemarthrosis

• Difficult to assess in young children
• Observe activities
• Unwillingness to use arm or leg
• Eating with opposite hand?
• Reaching for toys with one hand?
• Crawling instead of walking?
• Unwilling to wear shoes?

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Assessment of Hemarthrosis

• Visual exam
• Measure joint and contralateral joint
• Range of Motion
• Tenderness
• Bruising?
• Pain?
• Scale of 1-10

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Evaluation of Joint Bleeding

• Serial measurements to assess progress of
  treatment
• Measure in same place
• Use contralateral joint for comparison

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Muscle Bleeding

• History
• Traumatic injury?
• Timing of injury?
• Duration of symptoms?
• Worsening or improving?
• Treatment?
• Pallor, s/s anemia
• Condition of skin

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Assessment of large muscle bleeds

• Careful, serial monitoring of Hb levels
• Danger of significant blood loss in large muscle
• i.e. Quadriceps

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Iliopsoas

• Ask patient to lie flat, extend hip and knee
• Characteristic posturing
• Decreased ROM hip
• Palpate for mass in abdomen
• Observe carefully for parasthesias in thigh
• Imaging can be helpful
• Hip vs. Iliopsoas

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Assessment of Bleeding in small muscles

• Closed spaces
• Perform neurologic checks
• Forearm bleeding
• Observe capillary refill
• Careful monitoring of ability to use all fingers
• Question carefully about numbness/tingling

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Muscle Bleeding

• Helpful to have baseline measurements of arms and
  legs
• Dominant limb may be larger
• May be smaller if on limb with chronic joint
• Can lead to uncertainty when assessing acute
  hemorrhage

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Assessment of Mouth Bleeding

• Blood loss can be insidious
• Monitor Hb levels
• Careful history and assessment
• Observe for
• Pallor, lethargy
• Nausea, vomiting
• Abdominal pain

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Soft Tissue Bleeding

• Assessment
• Painful to sit or walk
• Interferes with activities of daily living
• Often not treated

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Treatment of Serious Bleeding

• Administer factor VIII or IX to achieve high
  level (70-100)
• Treat ASAP, before diagnostic evaluation
• Maintain factor VIII or IX levels above 30 until
  hemostasis achieved.
• Additional coverage for invasive procedures
• Treatment
• Replace factor as soon as possible.
• Follow local protocols.
• Supportive measures important.

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Assessment of Treatment

• Resolution of bleeding as expected?
• No?
• Check weight, dose, frequency
• Evaluate for adherence to treatment plan
• Evaluate for inhibitor development

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Maintain Communication with Patient/Family for
Optimal Follow-up
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Remember

• Life threatening bleeding episodes are rare
• When identified early and treated appropriately
  most bleeds can be adequately treated without
  long-term consequences

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