patients sustain a challenge that exceeds the capability of their hemostatic system, such as major surgery or trauma, invasive dental procedure or extraction, or menarche Emergency physicians may encounter patients who are referred for an abnormal coagulation laboratory result obtained by a primary care physician, often because of an expressed concern for bleeding or easy bruising, or because of a family history of a bleeding disorder Consider underlying coagulation disorders in patients who return with postoperative and traumatic bleeding that seems out of proportion to the clinical situation Infants may present to the ED with prolonged bleeding from the site of circumcision or the umbilical stump Older children may present with a pattern of mucosal bleeding including epistaxis or menorrhagia, or with deep muscle or joint bleeds, usually trauma associated Triage If a child presents with active bleeding, initial assessment should focus on the site and severity of hemorrhage and prioritize therapeutic interventions to achieve hemostasis Evidence of hemodynamic compromise should prompt rapid resuscitation efforts to reestablish circulating volume Consider the need for prompt surgical involvement if clinically indicated Clinical Assessment A detailed history of the patient’s prior bleeding events and a thorough family history are necessary to determine the level of concern for an underlying bleeding disorder Pertinent history includes: Are bleeding episodes related to mild–moderate trauma or procedures or they occur spontaneously? Is the bleeding typically a mucocutaneous pattern (e.g., epistaxis, oral bleeding, petechiae, easy bruising, GI bleeding, or menorrhagia)? Is there bleeding into the deep muscles or joints? Is there a history of poor wound healing? Are bleeding episodes more likely to occur hours versus days after a procedure or injury? Additionally, family history of responses to hemostatic challenges may suggest an inherited defect of hemostasis Mucocutaneous bleeding is usually associated with defects of primary hemostasis such as platelet count (see section on thrombocytopenia above) or dysfunction, or VWD Bleeding into deep muscles or joints, especially when spontaneous, is characteristic of hemophilia Poor wound healing or delayed bleeding following a procedure has been described with factor XI, factor XIII, and PAI-1 deficiencies A physical examination should focus on findings of active or recent bleeding including a careful HEENT and dermatologic examination