Approach to bleeding

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Overview in management of bleeding patients
for medical students.

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  • Approach to bleeding

    1. 1. Approach tobleeding disorder Kaipol Takpradit
    2. 2. Covered topics• Basic of hemostasis• Approach to a bleeding patient• Principle of treatment of a bleeding patient
    3. 3. Hemostasis• Primary hemostasis • Platelet • Vessel constriction • Tissue edema• Secondary hemostasis • Coagulation factors
    4. 4. Primary hemostasis• Consist of platelet, vessel wall• Initial step to stop bleeding• Disorder usually causes superficial bleeding (petechiae, purpura), persistent superficial bleeding
    5. 5. Platelet activation
    6. 6. Secondary hemostasis• Consist of coagulation factors• Defect causes delayed (1-2 hr.) bleeding• Usually causes deep or internal bleeding
    7. 7. Cause of bleeding diathesis• Local lesion e.g. gingivitis• Vasculopathy e.g. scurvy, amyloidosis, Osler-Weber- Rendu syndrome• Thrombocytopenia e.g. ITP, acute leukemia• Platelet dysfunction e.g. antiplatelet drug, Glanzmann’s thrombasthenia, Bernard-Soulier syndrome• Coagulation defect e.g. VKA, hemophilia
    8. 8. Approach to patients• Bleeding proper to trauma?• Bleeding is local or systemic?• Location of bleeding?• History of bleeding? • Previous challenging event • Spontaneous bleeding
    9. 9. Other considerations• Family history of bleeding diathesis• Underlying diseases of the patient• Concurrent medication • Antiplatelet drugs • Anticoagulant • Drug interaction
    10. 10. Investigation• Use to confirm or differentiate causes of bleeding• Empirically investigation can cause a lot of headache to treating physician • Investigations require high-skilled technician and prone to be error • Due to limitation of knowledges, investigation may not cover all aspects of coagulation system thus may be not well correlate with clinical
    11. 11. Investigation• Complete blood count • Can determine the quantity of platelets• Peripheral blood smear • Can evaluate some quality of platelets• Platelet aggregation test • Can evaluate functions of platelets in presence of certain agonists
    12. 12. Bleeding time• Can determine overall function of vessel wall and platelets• Require skilled technician to apply right pressure, site of skin puncture, size of lancet, depth, avoid contact to punctured site, etc• Also altered by Hct, platelet count• Thus in overall, there is a poor correlation between bleeding time and surgical bleeding
    13. 13. Coagulogram• Test on sum function of all factors in the path way• Can approximate function of coagulation but not all • Factor X activity has very few effect on aPTT • PT is more sensitive to factor VII and X than II and fibrinogen level • Factor XIII is not tested in coagulogram • Factor XII deficiency has prolonged aPTT but has no clinical bleeding
    14. 14. Coagulogram• Prolonged result indicate decreased level or from inhibition of clots formation • Deficiency of one or more factors • Inhibitor to factors • Protein interfering fibrin polymerization • Increased fibrinolysis
    15. 15. Mixing test• At least 50% of factor’s activity can produce a normal coagulogram• Normal activity in plasma is 100%• If patient’s plasma has 0% activity then mixing test should be able to correct the coagulogram• Normal plasma derived from pooled plasma of normal individual
    16. 16. Mixing test• Specific factor inhibitor is time dependent e.g. factor VII inhibitor, factor IX inhibitor• Unspecific inhibitor like antiphospholipid antibody cause an immediate prolonged mixing study
    17. 17. Other test• Venous clotting time• Urea solubility test• Factor assay• Activated clotting time• Thromboelastograph
    18. 18. Thromboelastograph
    19. 19. Principle of treatment• Local bleeding should be stopped by local mean• If the cause(s) can be corrected then do so • Antivenom for snake bite , etc.• For deficiency of a functional component, replacement of that component can be used• In presence of inhibitor, try to eradicate inhibitor or bypass the affected pathway
    20. 20. Local measure• Compression • Good for primary hemostatic defect• Antifibrinolytic drug e.g. tranexamic acid• Vasoconstrictor e.g. adrenaline• Fibrin glue• Surgical mean e.g. suturing, electrocauterization
    21. 21. Replacement• Blood component • Efficiently arrange the use of donated blood • Can separately store each components in their proper condition • Good blood banking is indicated by using of blood component
    22. 22. Replacement• Platelet concentrate • Contain platelet 5.5 x 1010/unit • Raise platelet about 5,000/µL • Contain RBC about 0.5 ml • Contain WBC about 108-109/unit The Thai Red Cross Society
    23. 23. Replacement• Pooled leukocyte poor platelet concentrate • Contain platelet 3.0 x 1011/unit • Raise platelet about 30,000/µL • Contain RBC about 5 ml • Contain WBC about < 2x 108/unit The Thai Red Cross Society
    24. 24. Replacement• Single donor platelet • Contain platelet ≥ 3.0 x 1011/unit • Raise platelet about 30,000/µL • Contain RBC about 5 ml • Contain WBC about < 106/unit The Thai Red Cross Society
    25. 25. Replacement• Fresh frozen plasma • Contain all coagulation factors • Should be used immediately after thawed • Supposed to have 100% activity of each factors • 1 ml contain factor 1 unit
    26. 26. Replacement• Cryoprecipitate • Contain factor VIII, factor XIII, vWF, fibrinogen • Each unit have factor VIII 80-100 units • 1 unit/10 kg dose can raise fibrinogen 100 mg/dL• Factor concentrates e.g. factor VIII concentrate, factor IX concentrate, recombinant factor VIIa
    27. 27. Bypassing agent• Prothrombin complex concentrate• Activated prothrombin complex concentrate (FEIBA ®)• Recombinant factor VIIa (NovoSeven ®)
    28. 28. Fin

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