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

Guidance for Outpatient Providers for Home Treatment, ED Referral
  • 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
  • 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
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
Revised: December 2021
Authors: R. Butler; L. Raffini MD; C. Witmer MD; C. Jacobstein MD; J. Lavelle MD