Management of Hemophilia and Head Trauma: A Survey of Current Clinical Practice among Pediatric Hematology/Oncology Physicians.

OBJECTIVE: The goal of this survey was to assess current pediatric hematologists/oncologists self reported practices regarding the management of pediatric patients with hemophilia who experience head trauma. PATIENTS AND METHODS: An email questionnaire was sent on March 2007 to members of The American Society of Pediatric Hematology/Oncology. The questionnaire included generalized questions regarding the clinical approach to pediatric patients with hemophilia and head trauma and specific management questions for two case scenarios. The case scenarios consisted of boys (16 to 18 months) with severe hemophilia and either a fall from 2 to 3 feet or a fall while running; both were well appearing. The case scenarios were then altered to assess if the physicians management would change. The alterations included 1. a large palpable hematoma at the sight of injury, 2. prophylaxis administered 24 hours prior, 3. head trauma occurred 48 hours prior to evaluation, 4. the patient had a soft helmet on at the time of injury, 5. one episode of emesis. RESULTS: The response rate to the email questionnaire was 37%, 397/1077. Of the 397 respondents 252 cared for patients with hemophilia and completed the survey. Twenty-eight percent (69/251) indicated that they utilized an institutional protocol for hemophilia and head trauma. Only 33% (82/250) recommend soft helmets for their toddler age patients and 28% (67/241) indicated that soft helmets could prevent intracranial bleeding. Eighty-nine percent (220/248) reported the routine use of computed tomography to evaluate patients with hemophilia and head trauma, although 41% (102/250) had concerns about CT imaging. The respondent’s highest ranked clinical variables for clinical decision making included the presence of signs and symptoms of ICH, prior history of ICH, and the mechanism of injury. There was no clear consensus as to the specific mechanism of injury that most likely results in an intracranial hemorrhage. The tables below demonstrate the percent response to the initial case scenarios followed by the percent response to the specified clinical change in the case: | | Case #1 | 1) Bruise | 2) Prophylaxis | 3) Injury 48 hours prior | 4) Soft helmet | 5) Emesis | |:----------------------------------- | ------- | --------- | -------------- | ------------------------ | -------------- | --------- | | (Represents 230 to 239 respondents) | | No Intervention (%) | 5.9 | 0.8 | 14.5 | 67.9 | 17.4 | 2.9 | | +Factor+CT (%) | 64.7 | 80.3 | 53 | 8.0 | 52.6 | 88.3 | | +Factor No CT (%) | 25.2 | 15.5 | 24.8 | 21.5 | 23 | 4.2 | | No factor +CT (%) | 4.2 | 3.4 | 7.7 | 2.6 | 7 | 4.6 | Case #1. Toddler with severe hemophilia and head trauma due to a fall from 2–3 feet | | Case #2 | 1) Bruise | 2) Prophylaxis | 3) Injury 48 hours prior | 4) Soft Helmet | 5) Emesis | |:------------------------------------ | ------- | --------- | -------------- | ------------------------ | -------------- | --------- | | (Represents 205 to 220 respondents.) | | No Intervention (%) | 18.6 | 1.9 | 20.9 | 66.4 | 27.8 | 3.7 | | +Factor+CT (%) | 51.8 | 79.5 | 48.3 | 8.5 | 44.4 | 84.2 | | +Factor No CT (%) | 25 | 15.3 | 23.7 | 7.6 | 21 | 5.6 | | No factor+CT (%) | 4.6 | 3.3 | 7.1 | 17.5 | 6.8 | 6.5 | Case #2. Toddler with severe hemophilia and head trauma due to a fall from running. CONCLUSIONS: The current self reported care of pediatric patients with hemophilia who sustain mild head trauma is diverse. Over half of the respondents reported the use of factor replacement and CT imaging for mild head trauma without signs or symptoms of ICH compared to the remaining respondents who would not intervene or only give factor replacement. Mild head trauma is a common event in childhood. This clinical variation has significant implications for individual radiation exposure, sedation risks, and cost. This diversity in reported care is likely secondary to a lack of studies that address what the true risk of ICH is after mild head trauma in patients with hemophilia.