# A 7-year-old child with hemophilia A is brought to the emergency department after falling from a bicycle. Which assessment finding would be the MOST concerning and require immediate intervention?

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## 문제

A 7-year-old child with hemophilia A is brought to the emergency department after falling from a bicycle. Which assessment finding would be the MOST concerning and require immediate intervention?

The nurse is assessing a pediatric patient with known hemophilia A following a bicycle accident.

## 보기

1. Swelling and tenderness at the left elbow joint
2. Small superficial abrasions on both knees with minimal bleeding
3. Complaint of mild headache and feeling "dizzy"
4. Severe abdominal pain with guarding and rigidity **✔ 정답**

**정답: 4**

## 해설

Severe abdominal pain with guarding and rigidity in a hemophilia patient following trauma indicates potential internal bleeding, which is life-threatening and requires immediate intervention.

In a patient with hemophilia A, the most critical concern after trauma is internal bleeding, especially intra-abdominal bleeding. Hemophilia A is an X-linked recessive bleeding disorder caused by a deficiency or dysfunction of coagulation factor VIII, which severely impairs the clotting process and significantly reduces the ability to form stable blood clots.

Severe abdominal pain with abdominal rigidity and stiffness in a hemophilia patient after trauma strongly suggests intra-abdominal bleeding, which can rapidly become fatal if not treated immediately. A rigid abdomen indicates peritoneal irritation from blood accumulation, while guarding refers to involuntary muscle contraction to protect the injured area. These symptoms require immediate factor VIII replacement therapy, fluid resuscitation, and potentially emergency surgery.

Internal bleeding in hemophilia patients can occur even with minor trauma due to the impaired clotting mechanism. Bleeding may not be immediately obvious externally, making clinical assessment crucial. Intra-abdominal bleeding can lead to hypovolemic shock, organ damage, and death if not treated promptly.

Priority nursing assessment focuses on identifying signs of internal bleeding, monitoring vital signs for shock, and preparing for immediate factor replacement therapy. Early recognition and intervention are critical to preventing life-threatening complications in pediatric hemophilia patients after trauma.

## 심화 해설

Clinical Priority in Hemophilia A Following Trauma

Hemophilia A is an X-linked recessive bleeding disorder caused by a deficiency of coagulation Factor VIII. In the setting of trauma, the primary nursing responsibility is the rapid identification of life-threatening hemorrhage. While musculoskeletal injury and external bleeding are common, internal bleeding into closed spaces or critical organs constitutes a medical emergency.

Analysis of Assessment Findings

The question requires differentiating between expected post-traumatic bleeding manifestations and a finding indicative of a potentially fatal hemorrhage. The most concerning finding is severe abdominal pain with guarding and rigidity.

- Option 1 (Swelling and tenderness at the left elbow joint): This presentation is consistent with hemarthrosis, a hallmark of hemophilia. Bleeding into the joint space causes swelling, pain, and limited range of motion. While it requires prompt factor replacement to prevent chronic joint damage, it is not immediately life-threatening.

- Option 2 (Small superficial abrasions on both knees with minimal bleeding): Patients with hemophilia do not bleed faster; they bleed longer due to an inability to form a stable fibrin clot. Superficial abrasions with minimal oozing are expected and can be managed with local measures and factor replacement. This is a low-priority finding.

- Option 3 (Complaint of mild headache and feeling "dizzy"): While any head trauma in a hemophilia patient warrants a high index of suspicion for intracranial hemorrhage (ICH), the description of "mild" headache and dizziness is a non-specific early symptom. As highlighted in the provided case report by Zahiri et al., ICH in hemophilia can present with headache and vomiting [1]. This finding requires continuous neurologic monitoring, but the absence of focal deficits or altered consciousness makes it a secondary priority compared to a rigid, guarded abdomen.

- Option 4 (Severe abdominal pain with guarding and rigidity): This is the most critical finding. Guarding and rigidity are classic peritoneal signs indicating serious intra-abdominal pathology. In a hemophilia patient with recent blunt trauma from a bicycle fall, this strongly suggests retroperitoneal or intraperitoneal hemorrhage. Bleeding into the abdominal cavity or retroperitoneal space can lead to rapid, massive blood loss and hypovolemic shock. The physical signs of a rigid, board-like abdomen represent an acute surgical abdomen requiring immediate intervention, including aggressive factor replacement and likely surgical exploration. This finding signals an active, uncontrolled hemorrhage into a space capable of holding the patient's entire circulating volume, making it the highest priority for immediate intervention to prevent death.

Clinical Reasoning and Priority Setting

Using the nursing process and Maslow's hierarchy of needs, physiologic survival takes precedence. The risk of exsanguination from an intra-abdominal bleed outweighs the risks of joint damage from hemarthrosis or the potential for neurologic deterioration from a mild headache. The rigid abdomen is a late and ominous sign of severe internal hemorrhage. While the case report by Zahiri et al. emphasizes that intracranial hemorrhage is a feared complication requiring high-dose factor VIII replacement and close monitoring [1], the immediate threat to airway, breathing, and circulation (ABCs) from hemorrhagic shock caused by abdominal bleeding demands the most urgent intervention. The nurse must immediately notify the provider, prepare for fluid resuscitation, and administer factor VIII concentrate as prescribed.

References (research sources)

- [1]Recurrent Strictly Unilateral Extra-Axial Intracranial Hemorrhage in Severe Hemophilia A Without Inhibitors Revealing a Suspected Dural Arteriovenous Fistula: A Case Report.Case reportZahiri H, Ghanam A, Tkak H, Azizi M, Rkain M. (2026) · DOI: 10.7759/cureus.106835

## 임상 시나리오

Hemophilia A Post-Trauma TriageIdentifying Life-Threatening Internal Hemorrhage
In a child with Hemophilia A following trauma, the priority is ruling out internal bleeding into closed spaces. Severe abdominal pain with guarding and rigidity is a classic peritoneal sign indicating retroperitoneal or intra-abdominal hemorrhage, which can lead to hypovolemic shock.

Immediate interventions include initiating the institutional massive transfusion or major hemorrhage protocol, administering Factor VIII concentrate (targeting a peak level of 80-100%), and preparing for urgent CT imaging and surgical consultation. Do not delay factor replacement for diagnostic studies.

CautionA head injury with only a mild headache still requires a low threshold for CT scanning and factor administration to prevent intracranial hemorrhage, but abdominal rigidity indicates active, potentially exsanguinating hemorrhage and takes immediate priority.

## 핵심 개념

- **Hemophilia A** — An X-linked recessive bleeding disorder caused by a deficiency of coagulation Factor VIII, leading to prolonged bleeding due to impaired fibrin clot formation.
- **Hemarthrosis** — Bleeding into a joint space, a hallmark of hemophilia, causing swelling, pain, and limited range of motion; requires factor replacement to prevent chronic arthropathy.
- **Guarding and Rigidity** — Involuntary muscle spasm and stiffness of the abdominal wall, a classic sign of peritoneal irritation often caused by internal bleeding or organ perforation.

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