Morning Report

April 27, 2015

Erin Bennett, MD, MPH, PGY-3

History of Present Illness

7 week old previously healthy male presents

with:
Bruising on sternum, knuckles
Vomiting, poor feeding, lethargy
Usual state of health until day PTA
Normal wet/dirty diapers
Marked irritability
Had been to InstaCare and to a chiropractor for

the bruising
Went to outside ED and was noted to have
difficulty breathing and bradycardia, so he was
intubated and transferred quickly

History
PMH:
Born full term. No complications with the birth or pregnancy.

Birth weight 3.1 kg

Maternal labs normal
No maternal medications during pregnancy except vitamins
Family History:
Paternal family members with Hereditary Spherocytosis
No significant history on maternal side
Both sides of family of Eastern European descent

Social History:
Lives with mother and father. Father recently incarcerated for

drugs and assault

Exam
Vitals: T 35, P 140, RR 40, BP 75/45, SpO2 95% on SIMV, rate 35, PEEP 5, PS 10
GENERAL: Intubated, sedated, in papoose.

HEAD: Anterior fontanelle full. Shape: normal.

EYES: Pupils small and sluggish but reactive bilaterally. No scleral icterus.
EARS: Normal EAC exam, no evidence of effusion or perforation.
NOSE: No mucous bilaterally.
OROPHARYNX: Moist mucous membranes. No cleft palate. Posterior pharynx nonerythematous and no lesions.
NECK: Normal ROM
LYMPH NODES: Normal lymph nodes.
CV: Normal Rate, regular rhythm. Murmur: none. Gallop: none. Pulses 2+, regular.
Capillary refill ~2 seconds.
LUNGS: Normal respiratory rate. Clear lung fields bilaterally with equal and complete
air entry. No retractions noted.
ABDOMEN: Soft, non-tender, non-distended, active bowel sounds, umbilical hernia.
EXTREMITIES: No clubbing, no cyanosis, no edema.
GU: Normal genitalia for sex, Tanner stage I.
NEURO/PSYCH: Intubated, sedated, not interacting.Moving all extremities equally, no
focal deficits.
SKIN: Bruises as follows:Large bruise over middle of sternum,right and left anterior
radial sides of wrists with ecchymoses, 4th metacarpal on bilateral hands with bruises
with small needle sites, right AC and right groin with ecchymoses, left thigh with
hematoma. Right shoulder with a small puncture abrasion on posterior side of arm.

Assessment
7 week old afebrile male with vomiting,

lethargy, fussiness, altered mental status, and

bruising.

Differential Diagnosis
Sepsis
NAT
Meningitis
Hemorrhagic Disease of the Newborn/Vitamin K

Deficient Bleeding
Hereditary Spherocytosis
Hemophilia
Von Willebrand
Thalassemia
Vascular Malformation
Leukemia

Work Up
Labs
CBC/diff: WBC 13.9 Hgb 7.5/Hct 23, Plts 399
HSV, CMV neg
CSF: Bloody, RBC 12,550, otherwise nml
CMP: only notable for bili 6.6
PT, PTT, INR all initially normal, then borderline

prolonged
PIVKA-II (Proteins induced in Vitamin K Absence)
2486 (normal <6.3)

Micro
Blood and urine cultures negative

Imaging
CT Head

1. The brain vasculature is displaced

secondary to the large amount of

subdural and parenchymal blood in
the right cerebral hemisphere.
2. No evidence of vascular injury or
vascular malformation.
3. Midline shift.
4. Diffuse loss of gray-white

differentiation throughout the right

superolateral hemisphere as well as
in the parietal lobe, temporal lobe,
and occipital lobe of the left cerebral
hemisphere.
5. Increasing effacement of the
basal cisterns as well as subfalcine
herniation.
6. Increasing scalp swelling.

Hemorrhagic Disease of the Newborn/

Vitamin K Deficient Bleeding (VKDB)
Early Onset
Within 24 hours
Likely maternal medications (anticonvulsants, warfarin)
Associated with intracranial hemorrhage in 25%
Incidence: 6-12%

Classic
Within 2-14 days
Cutaneous, GI, umbilical and circumcision-site bleeding
Incidence: 1.7%

Late Onset
2 weeks12 weeks of age
High frequency of intracranial hemorrhage
Cutaneous, GI, epistaxis, injection site, urine bleeding
Incidence: 4.4-7.2/100,000

Why newborns are at risk

Immature liver does not utilize Vitamin K

efficiently
Low Vitamin K stores and short half-life
Can take 90 days to normalize

Low Vitamin K in breast milk

Immature/altered gut flora
Poor placental transfer of Vitamin K

Management
Labs
Prolonged PT, INR, PTT (in severe cases)
Elevated PIVKA-II
Vitamin K levels not measured as often

Prophylaxis: Vitamin K 0.5-1 mg IM

Vitamin K activates II, VII, IX, X

Treatment
Vitamin K
FFP
Recombinant Factor VII
Surgery

References
https://

www-uptodate-com.ezproxy.lib.utah.edu/contents/overview-of-vitamin-k?source=see_lin
k&sectionName=Prevention+of+vitamin+K+deficient+bleeding+in+newborns&anchor=H19#H1
Schule, R, Jordan, L, Morad, A, et al. Rise in Late Onset Vitamin K Deficiency Bleeding in
Young Infants because of Omission or Refusal of Prophylaxis at Birth. Pediatric Neurology.
2014; 50: 564-568.
AAP.org