This document discusses the approach to patients presenting with bleeding disorders. It outlines that the first steps are to determine the pattern of bleeding and identify any "red flags" indicating urgent need for resuscitation. The pattern of bleeding can help narrow the potential causes, such as vascular defects causing bleeding into joints/muscles or platelet/coagulation defects causing mucous membrane bleeding. Red flags requiring immediate treatment include signs of shock, hypotension, oliguria or central nervous system bleeding. A thorough history, examination, and laboratory workup can then help diagnose the specific bleeding disorder.

1. BLEEDING DISORDERS; A
CLINICAL APPROACH
PACES Station 5
Mamdouh L Dorrah
MRCP-UK London

2. Causes of bleeding disorders
• Vascular defects
a) Congenital; Osler-Weber-Rendu syndrome, Ehler-Danlos Syndrome,
Pseudoxanthoma elasticum.
b) Acquired; Senile Purpura – Steroid therapy – Scurvy – Henochschonlein
Purpura – Infection.
• Platelet defects
a) Decreased platelet production
b) Increased platelet destruction
c) Non-functioning platelets.
• Coagulation defects
a) Congenital; Hemophilia – Von Willebrand disease.
b) Acquired; Anticoagulants – Liver disease – Malabsorption – DIC.

3. Approach; Introduction
In approaching a patient with a bleeding disorder, it is crucial to
determine the pattern of bleeding and the presence or absence of red
flags.
Identification of the pattern of bleeding is important to shortlist the
differential diagnoses.
Spotting the red flags is essential as a guidance for arrangement of a
proper management plan. The presence of red flags indicates the
necessity and urgency of immediate resuscitation.

4. Approach; pattern of bleeding
• Bleeding due to vascular and platelet defects results in bleeding into
skin and bleeding from mucus membranes.
• Bleeding due to vascular defects results in bleeding into joints and
muscles.

5. Approach, Red Flags
Immediate resuscitation is indicated in the presence of any of the
following red flags;
1. Dizziness – shock – coma.
2. Hypovolemia.
3. Postural hypotension
4. Oliguria.
5. CNS bleeding – Meningism – Neurological manifestations

6. Approach; History taking
History of the Presenting Complaint “HPC”
• Bleeding pattern; Bruising? “ onset – course –
duration – distribution” – Bleeding “ site –
frequency – aggravating factors – trauma” – Other
sites of bleeding? “ GIT- GUT- URT-CNS”.
• Red flags; Dizziness- Shock – Coma – Postural
hypotension – Oliguria – CNS bleeding “
• Other associations; Recent blood loss – Blood
donation – Blood transfusion.
Past Medical History
SLE? CTD? Platelet
disorder? Bleeding
disorder?
Drug History
Antiplatelet? –
Anticoagulants? Heparin?
Herbals?
Family History
Same condition?
Bleeding disorder?
Cancer?
Social History
Impact
Concern

7. Approach; Clinical examination
Rash; Morphology - Distribution
Signs of Anemia
Face & Mouth for signs of HHT
Abdomen for Organomegaly
Red Flags;
• Pulse & JVP for shock and
hypovolemia.
• CNS; Abbreviated mental score and
neurological examination.
Laboratory work up
• FBC.
• Blood film.
• PT.
• APTT.
• Fibrinogen and FDPs.
• LFTs.
• Viral hepatitis serology.
• Autoimmune profile.
• HIV serology; obtain a verbal consent.
Remember !
Spotting the red flags is essential as a guidance for
arrangement of a proper management plan. The presence of
red flags indicates the necessity and urgency of immediate
resuscitation.

8. Anticoagulation; How to approach?
History
• Dose?
• Indication?
• Last INR?
• Bleeding? Bruising?
• Anemia?
• Yellow anticoagulant record
book?
• Factors that have the potential to
cause INR instability? Alcohol –
New medication - Type of diet?
Examination
• Pulse.
• BP
• CVS examination

9. Thank you