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

Child with Hemophilia and Head Trauma
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.
Examples of trivial head trauma:
  • Does not require treatment/
    ED referral:
  • Hit lightly on the head by a toy
  • Mild bump against an object
  • Examples of mild head trauma:
  • Fall from own height
  • Fall from height < 3 ft
  • Examples of significant head trauma:
  • 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
Home Correction
Head CT and Hematology Consultation
Admission Criteria
  • Abnormal Head CT
  • Focal exam
  • Persistent symptoms
  • Significant mechanism
    • LOC, fall > 3 ft., etc.
  • Patient with Inhibitor — need for additional factor infusion
Discharge Criteria
  • Normal head CT
  • Asymptomatic
  • Mild mechanism
  • Ability of family to do follow-up care
Posted: August 2005
Revised: October 2011, May 2012, May 2017, October 2019
Authors: R. Butler; L. Raffini MD; C. Witmer MD; C. Jacobstein MD; J. Lavelle MD