Large intracerebral hemorrhage in the setting of vitamin K prophylaxis refusal

Vitamin K is a vital component of prophylactic treatment in newborns, as deficiency leads to inadequate synthesis of coagulation factors. Vitamin K deficiency bleeding (VKDB) can lead to gastrointestinal, mucocutaneous, or intracranial hemorrhage. Unfortunately, the rise in vaccine hesitancy has been paralleled by a rise in refusal of vitamin K prophylaxis at birth. Case report Here, we present the case of a 2-month-old who presented to the emergency department with a large ICH due to a lack of vitamin K prophylaxis. The patient presented to the emergency room (ER) unresponsive with a blown pupil. Computed tomography (CT) scan showed a large intraparenchymal hemorrhage with substantial midline shift. The patient's coagulation studies resulted with INR > 15, PTT > 200, and TEG > 69; he had not received vitamin K prophylaxis at birth. Vitamin K was given, and aggressive transfusion protocol was started in the ER. He was closely monitored in the pediatric intensive care unit (PICU) and safely taken for decompressive hemicraniectomy once coagulopathy was reversed. Post-operatively, he remained paralyzed on the oscillator for ventilatory support due to transfusion-related acute lung injury (TRALI). He was eventually able to be weaned from paralysis, sedation, and respiratory support and was discharged to home with outpatient follow-up and rehabilitation. He has since undergone cranioplasty, and at 6 months follow-up, he continues to progress, is appropriately alert, and moves all extremities grossly symmetrically.

Newborns who do not receive vitamin K at birth remain at risk for intracranial hemorrhage. In this case, it was vital to reverse coagulopathy before taking the patient for decompressive surgery. Teamwork amongst the emergency room, critical care, anesthesia, and neurosurgical teams was crucial to safely manage this patient's large intracranial hemorrhage.