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Morning Report

Melanie Nelson, PGY-2


DECEMBER 3, 2018
Gen Peds Clinic
New patient visit: 5 wo female with fussiness

Vitals: T 37.6 P 124 R 32 BP 106/67


Gen Peds Clinic
New patient visit: 5 wo female with fussiness

Vitals: T 37.6 P 124 R 32 BP 106/67

 3 days of unexplained bruising, 1 day of fussiness/vomiting


 Uncomplicated pregnancy and delivery, born at home with lay midwife, hep B and
vitamin K not given

 No family history of bleeding/clotting disorders, autoimmune disease


 Lives with parents and 5 siblings. No smokers in home, no pets. Rear facing car seat. No
known sick contacts. Does not attend daycare/babysitter.
Physical Exam
Constitutional: active and well-appearing infant, crying but is easily consoled by mother
Head: Normocephalic and atraumatic. Normal fontanelles.
Eyes: Conjunctivae normal without icterus, PERRL, EOMI. Red reflex present bilaterally
Mouth: No palatal petechiae noted.
Respiratory: CTAB
Cardiovascular: RRR no M/R/G
Abdominal: Soft, NT/ND. Bowel sounds are normal. No hepatosplenomegaly.
Neuro: Alert and cooperative. Grossly normal strength and tone.
Skin: there are approximately 1.5-2 circular ecchymoses located on the patient's posterior
left upper arm, right flank, left lower back, and left upper back.
Differential?
Differential?
ID: Onc:
- sepsis - neoplasm

Heme: Rheum:
- Vitamin K deficiency bleeding - ITP/autoimmune disease
- Thrombocytopenia - vasculitis
- platelet dysfunction
- coagulation factor deficiency

Other:
- NAT
Suspected vitamin K deficiency bleeding
PLAUSIBLE HISTORY + EVIDENCE OF COAGULOPATHY = PRESUMPTIVE
TREATMENT WITH IV VITAMIN K
Suspected vitamin K deficiency bleeding
PLAUSIBLE HISTORY + EVIDENCE OF COAGULOPATHY = PRESUMPTIVE
TREATMENT WITH IV VITAMIN K

LATE ONSET VKDB CARRIES A 22% MORTALITY RATE AND 25-67% RATE
OF ADVERSE NEURODEVELOPMENTAL OUTCOMES
What Next?
What Next?
Transfer to PCH, direct admission to IMSU
Labs? Imaging?
Labs? Imaging?
CBC: WBC 12.6, Hgb: 11.2, Hct 31.7, Plt 397

CMP: Na 136, K 4.6, Cl 107, CO2 20, BUN 10,


Cr 0.24, Glu 126, Tbili 3.8, Dbili 2, AP 416, AST
42, ALT 19, GGT 51

PT/INR: PT >100, PTT >150, INR >11


Labs? Imaging?

CBC: WBC 12.6, Hgb: 11.2, Hct 31.7, Plt 397

CMP: Na 136, K 4.6, Cl 107, CO2 20, BUN 10, Cr 0.24, Glu 126, Tbili 3.8,
Dbili 2, AP 416, AST 42, ALT 19, GGT 51

PT/INR: PT >100, PTT >150, INR >11


Head CT

Head CT:

1. Moderate ventriculomegaly of the lateral and third ventricles with


small amount of dependent interventricular hemorrhage.
Asymmetrically increased density of the left choroid plexus glomus
suggests choroid plexus hemorrhage may be the source of
interventricular hemorrhage.

2. Focal hemorrhage along the left lateral temporal lobe probably


either subarachnoid or subpial hemorrhage more likely than
parenchymal hemorrhage. No midline shift or mass effect.
Next steps?

GIVE VITAMIN K
Next steps?
Give vitamin K → 5 hours later: PT 13.4, PTT 33, INR 1.0
Next steps?
Give vitamin K → 5 hours later: PT 13.4, PTT 33, INR 1.0

Vitamin K Deficiency Bleeding


Vitamin K Deficiency Bleeding
Clinical Features
 Early onset (24 hours), usually 2/2 maternal medications (warfarin, cephalosporins,
anticonvulsants). 25% develop ICH
 Classic VKDB (1-4 weeks). Typically present with GI or umbilical bleeding
 Late-onset VKDB (1-8 months). 50% present with ICH
Vitamin K Deficiency Bleeding
Epidemiology

 Pre-prophylactic vitamin K:
 Late VKDB: 25/100,000 (80 in low/middle income
countries, 8.8 in high income countries)
 Late or classical VKDB: 327/100,000
 Post-prophylactic vitamin K:
 98% reduction - 6/100k in LMIC, 0.76/100k in HIC
 NNT 1275, but cost-effective
 Risk factors for VKDB despite vitamin K at birth include
exclusive breast feeding, diarrhea, antibiotic use
Vitamin K Deficiency Bleeding
Pathogenesis
 Immature liver utilizes vitamin K inefficiently
 Low vitamin K stores
 Low vitamin K content in BM
 Sterile gut
 Poor placental transfer of vitamin K
Vitamin K
Deficiency
Bleeding
Pathogenesis
FACTORS II, VII, IX, AND X ARE
VITAMIN K DEPENDENT
Vitamin K Deficiency Bleeding
Prevention/Treatment
 Prevention: 0.5-1 mg vitamin K IM at delivery
 Alternative: 2 mg vitamin K PO at 1, 4, and 8 weeks – not as effective
 Treatment: 1-2 mg vitamin K IV
 Expect resolution of coagulopathy in 2-3 hours
 Can add FFP for severe bleeding
Case Outcome
 Over the next several hours, worsening mental status  PICU for urgent EVD placement
 Developed clinical seizures, started on phenobarb  Keppra

 Now, seizures have resolved, increased upper extremity tone


Sources

Up to Date

Sankar MJ, Chandrasekaran A, Kumar P, Thukral A, Agarwal R, Paul


VK. Vitamin K prophylaxis for prevention of vitamin K deficiency
bleeding: a systematic review. J Perinatol. 2016;36 Suppl 1(Suppl
1):S29-35.