Child with

bruises

Dr Fatma Ben Amer

Pediatric specialist in Tripoli children hospital

What is the bruises??

It could be normal or It is a sign of a
dangerous disease or child abuse?
What are diseases could cause a bruises??
If child presented to me with bruises... from
where I can start.??
If I will order the investigations what could it
be??
How I can mange a child with bruises?

Objective
By end of this lectures you will able to

Define the bruises .

To recognize the feature that would indicate
non accidental injury (NAI)
Know the differential diagnosis of child with
bruises
How to approach to child with bruises

What are the bruises??

bruise

(acontusionor anecchymosis)

Is a discoloration of the skin due to extravasations

of blood into the underlying tissues;
usually as a result of injury, but sometimes occurring
spontaneously in case of bleeding
disorders or disease of the blood vessels. .

Bruises Is
adiscolorationoftheskin

It is not possible to reliably predict the age of an ecchymoses based on its color.
However, red, blue, or purple bruises suggest recent lesions. Yellow, brown, or green
bruises tend to be older, healing lesions. Ecchymotic lesions may take weeks to
resolve.

Is every discoloration of skin

mean bruises
??

skin findings that mimic

bruising

such as slate-grey nevi (Mongolian blue spots), hemangioma,

skin staining from dyes or other skin discolourations

bruise

(acontusionor anecchymosis)

Is a discoloration of the skin due to extravasations

of blood into the underlying tissues;
usually as a result of injury, but sometimes occurring
spontaneously in case of bleeding
disorders or disease of the blood vessels. .

Bruises
usuallyasaresultofinjury

The injury could be an accidental

Injury could be a nonaccidental injury

(NAI)

Red flags for nonaccidenal injury

(NAI)
(child abuse)

Bruises in babies
Bruises that are clustered or patterned (patterns may include handprints,
loop or belt marks, bite marks)
Bruises that do not fit with the causal mechanism described
Bruising area

bruise

(acontusionor anecchymosis)

Is a discoloration of the skin due to extravasations

of blood into the underlying tissues;
usually as a result of injury, but sometimes occurring
spontaneously in case of bleeding
disorders or disease of the blood vessels. .

How our body normally

can stop the bleeding
??

Hemostatic mechanism

Causes of bruises

disruptions in vascular integrity

(trauma, infection, vasculitis, collagen
disorders)

abnormalities in homeostasis
(thrombocytopenia, abnormal platelet
function, clotting factor deficiency, or
abnormal clotting factor function)

Differential diagnosis of
bruises

How to Approach to child

with bruises??

Approach to child with

bruises
History
Examination
investigation

History.
1.

Personal data: age ,sex.

2.

PRESENTING COMPLAINT :-

Onset of symptoms :Acute onset verse recurrent bruises since infancy .

Site .
Other site of bleeding:

mucosal bleeding (gingival , epistaxis, menorrhagia) or bleeding into the joints ,Blood in
the stool or urine.

Preceding/Precipitating event - Trauma, URTI

Extent/ Severity of bleed
CNS intracranial hemorrhage (ICP/ SOL): nausea, vomiting, headache, weakness
Symptomatic Anemia: postural giddiness, pallor, fatigue, chest pain, SOB, palpitations,

Systemic review (Search for Etiology)

Infections: Fever, RN, cough, , vomiting, diarrhea

Leukaemia / aplastic anaemia: fatigue, wt loss+ bone pain

liver problem: jaundice ,abdominal pain / distension

History.

Prior bleeding history

Birth cephalohematoma Umbilical stump bleeding , post circumcision
Postvenipuncture bleeding, dental extractions

Family history of bleeding

Male relatives affected (Hemophilia, X-linked Recessive trait)

Female relatives - Menstrual and Obstetric Hx

Recent medications

Aspirin, NSAIDs Anti-platelet

Warfarin Vit K inhibitor
Anti-convulsants Thrombocytopenia
Penicillin .

Nutrional history
Patients with severe malnutrition or restricted diets may be at risk for
scurvy or vitamin K deficiency.

Past medical history

renal , hepatic disease, congenital heart disease, and malabsorption
Unexplained anemia .History of blood transfusion

Physical examination..

General examination
- ill-appearing and/or hemodynamically unstable need to be rapidly assessed to
determine the underlying etiology.
- Signs of anemia: Pallor , HR, BP, Systolic flow murmurs or jaundice
- Mucosa : Nasal (Epistaxis), Gingival
-Skin - . The distribution and size and shape of brusises
-Lymph nodes ..leukemias or viral infections (infectious mononucleosis, CMV)
- Extremities and joints -. Intramuscular Bleed, Hemearthrosis
Joint contractures ( chronic hemearthroses

Abdominal examination
Hepatomegaly may signal an underlying hepatic disorder
Splenomegaly can be seen in infectious mononucleosis, leukemia, hepatic disease, and
the storage diseases.

Neurologic evaluation
Complete neurologic assessment is mandatory when there is suspicion of head trauma in
the face of a bleeding diathesis. The eyes should be examined for the presence of
conjunctival, scleral, or retinal hemorrhage

Investigation.

Complete blood count (CBC).

Peripheral blood smear.
Prothrombin time (PT):
asses the activity of factors II, V ,VII and X
(NR <12 sec beyond neonate)
Partial thromboplastin time( PTT),
asses the activity of factors II ,V,VIII,IX,X,XI and XII
(NR 25-40 sec beyond neonate) .
Thrombin time - test deficiency or dysfunction of fibrinogen
factor VIII, factor IX and factor XI assay.
Quantities fibrinogen assay
von Willebrand antigen and ristocetin cofactor activity
platelet function screen
Renal and liver function test.

Interpretation of some clotting screen

PT PTT TT

Possible abnormality

Factor VII
Liver disease
Vitamin K deficiency

Factor VIII (hemophilia A or VWD)

Factor IX,XI,XII

Fibrinogen (quantities or qualitative)

Factor II, V,X (common pathway)

Liver disease and vit k deficiency

Disseminated intravascular coagulation (DIC)

Sever hypo- or afibrinogenemia

Table (1) Clotting screen

Management of acute
hemorrhage in bleeding diathesis

Check ABCs and ensure vitals are stable

Assess and identify the site of bleeding
Apply pressure to bleeding site
Insert 2 large bore IV catheters and send blood for FBC, U/E/Cr, PT/PTT .
Infuse 20ml/kg of N/S over 20 mins (up to 3x) if till refractory, consider inotropes.
Correct coagulopathy

Fresh frozen plasma (10-20ml/kg)

Cryoprecipitate
Factor VII/IX infusions
Desmopression stimulates Factor VII and vWF
Antifibrinolytics (tranexamic acid, epsilon amino caproic acid)

Analgesia for pain relief

Once acute bleeding has been managed, evaluate with history, physical examination and
investigations to ascertain type of bleeding disorder.
Specific Treatment (with regards to underlying etiology)

Factor replacement therapy

Coagulopathy - haemophilia

Case presentation

Case presentation1

3 year old girl presented in ER with scattered petechiae and

ecchymoses over the body and lower extremities she had h/o URI
1 Week back, Physical exam normal, no hepatosplenomegaly.
WBC-7,000, Hb 12.8, Plts-5,000, Diff: Normal,

Next step
1. perform a bone marrow aspirate to confirm the diagnosis
2. Non-accidental injury; skeletal survey to rule out bony fractures
3. treatment with either IVIG or anti-D

ITP
(idiopathic thrombocytopenic
purpura)

ITP Usually acute onset; immune mediated; post viral

Peak 2-5 years of age, males=females
Spontaneous bruises, petechiae
O/E no lymphadenopathy (LN), hepatosplenomegaly.
CBC- other cell lines normal, large plts on smear
Treat if plt< 10,000 or wet ITP, avoid NSAIDS
Treat- IVIG best response, 48-72 hours;
Anti-D
Steroids good response, SE, inexpensive, need BM

Case presentation2

A healthy 2-day-old boy born at term undergoes

circumcision. Bleeding noted at the site 10 hours
after the procedure and increased steadily over
the past 4 hours. Findings on exam are
unremarkable except for bleeding along 2 to 3
mm of the surgical site; no petechiae or purpura.

1. Disseminated intravascular coagulation

2. Factor VIII deficiency hemophilia
3. Immune thrombocytopenic purpura
4. Neonatal alloimmune thrombocytopenia
5. Von Willebrand disease

Hemophilia

Hemophilia is commonest sever inherited

coagulation disorder caused by a deficiency
in the a factor VIII and IX.
Hemophilia A and B are X-linked recessive
disorders and 1/3 of the cases of hemophilia
are new mutations

Hemophilia

Affected individuals develop a variable phenotype of hemorrhage

into joints and muscles, and prolonged bleeding from wounds

The severity of the disorder is determined by the degree of

clotting factor deficiency

Normal factor VIII or IX level = 50-150%

Mild hemophilia

Moderate hemophilia

factor VIII or IX level = 6-50%

factor VIII or IX level = 1-5%

Severe hemophilia

factor VIII or IX level = <1%

Hemophilia

Complications of Bleeding

Flexion contractures

Joint arthritis / arthropathy

Chronic pain

Muscle atrophy

Compartment syndrome

Neurologic impairment

Treatment of Hemophilia

replacement therapy

On demand

Prophylaxis

DDAVP
Antifibrinolytic Agents
Supportive measures

Icing
Immobilization
Rest

summary

By the end..

Define the bruises .

To recognize the feature that would indicate
non accidental injury (NAI)
Know the differential diagnosis of child with
bruises
How to approach to child with bruises

Home massage
Dont forget good focused history
and proper examination and or
specific target investigation can
answer your patient,s problem and
give him proper
Diagnosis and right management