Treating & Managing Bleeds
Bleeds (or bleeding episodes) are a complication of hemophilia that occur in people of all ages with the disorder. Treating bleeds promptly and being vigilant in monitoring treatment outcomes are crucial to preventing the development of other serious complications like joint disease and pain.
What Is a Bleed?
A bleed occurs when blood vessels are torn—whether outside the body (like on the skin), or internally (like in a joint or muscle). The tear in the vessel causes blood to leak out into the surrounding tissues. In a person without hemophilia, the body reacts by covering the tear with platelets, tiny cells that contain clotting factor that are less than 1/10,000 of a centimetre in diameter. The platelets stick to the tear and form a "scab," which is called a fibrin plug, and the bleeding stops quickly.
However, people with hemophilia do not produce any or enough clotting factor, causing platelets to stick together less efficiently and resulting in a weaker fibrin plug. Their blood will clot eventually, but it takes much longer than in a person with the normal amount of clotting factor.
How & Where Bleeds Occur
In people with hemophilia, bleeds may occur as a result of an injury, such as a cut or fall. Bleeding also occurs during surgery. For people with severe hemophilia, bleeding may be spontaneous, meaning there is no apparent cause. Internal bleeds occur most often within a joint or muscle. The most commonly affected joints are the knees and elbows, but bleeds may also occur in the ankles, shoulders, wrists, and hips. The most serious muscle bleeds occur in the groin, forearm, and calves.
Treating Bleeds with Factor Replacement
Bleeding can be controlled in people with moderate or severe hemophilia by infusing (injecting) the clotting factor they lack directly into their bloodstream. Treatment should be individualized to each patient, so be sure to communicate with your healthcare providers and Hemophilia Treatment Centre (HTC) about when and how you or your family member should have factor nifusions. But here are some common approaches:
- Single daily infusions of clotting factor concentrates are often given to treat muscle or joint bleeding. When the muscle or joint has returned to normal, the doctor may recommend stopping daily treatment.
- In some cases, especially with prompt treatment, one factor infusion is enough. In other cases, treatment is given for several days.
- For more serious bleeding, the patient may need to receive infusions 2 to 3 times each day, for 10 to 14 days.
When Is Medical Care Necessary?
For more serious bleeds, such as injuries to the head, neck, chest, or abdomen, patients can infuse clotting factor at home—but they should be seen by a medical professional as soon as possible, either at their HTC or the nearest emergency room.
Treatment Approaches
While factor infusions may be given at a treatment centre or doctor's office, many patients and their families also learn to infuse factor treatment on their own. With proper training and education, this means they can treat most joint and muscle bleeds, as well as mouth and nose bleeds, at home.
Sometimes factor treatment is given on an ongoing, regular basis even when no bleeding is occurring. This treatment approach is called prophylaxis, and its goal is to maintain constant levels of factor in the patient's blood to try to prevent bleeds from happening. Your doctor can tell you more about whether prophylaxis is an appropriate treatment approach for you or a loved one.
First Aid to Help Manage Bleeds
In addition to factor treatment, first aid can also help slow bleeding, especially for minor bleeds in a joint, muscle, or soft tissue. The appropriate first aid steps are rest, ice, compression, and elevation—often abbreviated RICE—and they are commonly used for many types of injuries, including those suffered by professional athletes. Here's a summary of the approach:
- Rest - The area of the bleed should be rested. For instance, someone with an ankle or knee bleed should keep off their feet and avoid physical activities. It can be useful for people with hemophilia to keep a set of crutches at home. If there is a lot of swelling or if movement is difficult and painful, the joint or muscle may need to be immobilized by a half-cast or a splint for 2 or 3 days (any longer and the joint can become stiff and the muscles weak, making the joint more prone to re-injury).
- Ice - Applying ice helps control swelling and reduce pain. Crushed ice in a plastic bag or a bag of frozen vegetables, wrapped in a towel, work well. It is very important not to apply the ice for too long—10-15 minutes at a time, every two hours, is long enough.
- Compression - Apply pressure on the bleed area to help "pinch off" the blood vessels and slow down the bleeding. Compression of a joint or muscle bleed is done by using an elastic bandage (tensor): wrap the injured part in a figure-eight pattern. Watch carefully for coolness, numbness, or a change in color in fingers or toes—if these occur, remove the bandage and re-wrap it less tightly. An alternative is a Tubigrip® sleeve. If the injury is very sore, compression may increase the pain; if so, rewrap the injury less tightly or remove the bandage altogether.
- Elevation - Placing the area of the bleed at a level higher than the heart helps decrease the pressure in the blood vessels and slow the bleeding. Resting the injured body part on pillows can help make this step more comfortable.