Andrew Atkins is Haemophilia Clinical Practice Consultant, Royal Adelaide Hospital
The availability of clotting factor in Australia has led to greater opportunities in pursuing lifestyle and occupational activities. But while the risk of bleeding is reduced with prophylaxis or ‘pre-activity’ doses, it is still possible to have a bleed while ‘covered’ with factor.
While the signs/symptoms of bleeding into joints and muscles are emphasised often, and may become obvious due to repeated experiences, the warning signs of internal head (intracranial) bleeding can be more general, and depending on circumstances, not immediately taken as a potentially serious sign.
Intracranial bleeding could be described as the most dangerous of bleeds, as it can quickly lead to permanent cognitive and physical deficits, or death.
Some of the warning signs of intracranial bleeding include:
If any of these symptoms occur following a blow to the head then medical attention should be sought without delay, however minor the blow may have apparently felt.
If any blow to the head makes you ‘see stars’ or fall down, or make you want to sit down, or if it caused you to lose consciousness, then present to an Emergency Department as soon as possible. If you are at home and have factor accessible, then self-administer a dose before going to the Emergency Department.
In some instances the only symptom felt may be a persistent headache with no recall of a blow to the head. At our adult Haemophilia Treatment Centre over the past several years there have been four occurrences of intracranial bleeding. One of these was a man with type 2 von Willebrand Disease who fell from a ladder, and was retrieved by ambulance to the Emergency Department. Another man with severe haemophilia A on prophylaxis suffered an intracranial bleed without an apparent head injury. The two other occurrences were men with mild haemophilia who both did not recall a blow to the head at the time of admission and diagnosis (although one later recalled a minor blow). While all three men with haemophilia sought attention for their persistent headache, the delay for each of them between onset of symptoms and presentation resulted in more significant bleeding, effects and rehabilitation.
In contrast, another South Australian man, who has moderate haemophilia A, was bashed numerous times to the head and face and robbed of his wallet while in Bali in April. He was able to return to his hotel room, where he was found in a pool of blood some hours later by hotel staff. He was airlifted in an induced coma to Royal Perth Hospital where he spent three days in intensive care. Amazingly, despite his injuries including facial fractures, He suffered no intracranial haemorrhage. He is now back in Adelaide and recovering well. His advice to others travelling overseas is to ensure they have travel insurance, and wear a medical alert bracelet – he didn’t, and his card was stolen along with his wallet, meaning the hospital in Bali did not know of his haemophilia until his relatives were contacted in Australia.
So the correlation between severity of injury and internal bleeding can be poor – while heavy blows may not cause a bleed, don’t assume that a small blow won’t. While it’s always inconvenient to interrupt one’s plans and attend the Emergency Department, suspected cases are triaged as high priority, meaning waiting times are short. And those who have attended the Emergency Department and received the ‘all-clear’ regard the inconvenience as a small price for the peace of mind.
As a final point, haemophilia and head injuries are not the only risk factors for intracranial bleeding – other known risk factors include high blood pressure and liver disease. In fact, two of the haemophilia patients mentioned above did have liver disease which most likely contributed to their intracranial bleeding. So see your local GP and have your blood pressure checked, and for those living with hepatitis, it is worthwhile seeing your liver specialist if you have not done so recently.
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