Bleeding tendency
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This document outlines an approach to evaluating bleeding tendencies. It involves taking a thorough history, conducting a physical exam, and performing laboratory tests. Screening tests like the PT, APTT, and platelet count are used initially, followed by more specific diagnostic tests based on results. Identifying the underlying cause allows for targeted therapy such as factor replacement or drugs.
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Bleeding tendency
- 1. APPROACH TO BLEEDING TENDENCY Hamad Emad H. Dhuhayr
- 2. CONTENT • Overview • approach to bleeding tendency 1. Taking history 2. Physical examination 3. Laboratory • references
- 3. VASCULAR CONTRACTION 1. Local myogenic spasm 2. Local autacoid factors from traumatized tissue and blood platelets 3. Nervous reflexes
- 4. Red blood cell Platelet
- 5. Red blood cell Platelet
- 6. Red blood cell Platelet Von Willebrand factor
- 7. Red blood cell Platelet Von Willebrand factor
- 8. Red blood cell Platelet Von Willebrand factor
- 9. Red blood cell Platelet Von Willebrand factor
- 10. Red blood cell Platelet Von Willebrand factor
- 11. Red blood cell Platelet Von Willebrand factor
- 12. Red blood cell Platelet Von Willebrand factor
- 13. Red blood cell Platelet Von Willebrand factor
- 14. Red blood cell Platelet Von Willebrand factor
- 15. Red blood cell Platelet Von Willebrand factor Fibrin polymer
- 16. Red blood cell Platelet Von Willebrand factor Fibrin polymer
- 17. Red blood cell Platelet Von Willebrand factor Fibrin polymer
- 19. EVALUATION OF THE PATIENT •HISTORY •PHYSICAL EXAMINATION •LABORATORY EVALUATION
- 20. History taking Identify if the bleeding problem is due to Local vs. Systemic defect Location: single vs. Multiple sites Severity: spontaneous? Appropriate to trauma? Hereditary vs. Acquired disorder Onset Family history Underlying disease Medication Primary vs. Secondary hemostatic disoder
- 22. Primary Hemostatic defect Secondary Hemostatic defect
- 23. PHYSICAL EXAMINATION • Current hemorrhage • Nature and extent • Intercurrent illnesses • Liver disease • Petechiae/ecchymoses
- 24. LABORATORY ASSESSMENT • GUIDED BY HISTORY • SCREENING TESTS • PT • APTT • PLATELET COUNT • FIBRINOGEN • THROMBIN TIME
- 25. ASSESSMENT OF PRIMARY HEMOSTASIS PLATELET COMPLETE BLOOD COUNT (CBC) BLEEDING TIME/ PFA-100 PLATELET AGGREGATION STUDY BLOOD VESSEL BLEEDING TIME VON WILLEBRAND FACTOR (VWF) BLEEDING TIME VWF ANTIGEN, VWF: RCO, VWF MULTIMER, FVIII
- 26. COMPLETE BLOOD COUNT (CBC) PLATELET NUMBER NORMAL PLATELET COUNT: 150,000 –400,000/UL > 100,000/UL BLEEDING UNLIKELY < 20,000/UL ↑ RISK FOR SPONTANEOUS BLEEDING MUST EXCLUDE PSEUDOTHROMBOCYTOPENIA ASSESS FOR PLATELET MORPHOLOGY
- 27. Etiology of Thrombocytopenia Decreased Production • Hypoproliferation • Aplastic Anemia, Amegakaryocytic • Ineffective Thrombopoiesis thrombocytopenia, infection, toxins, drugs Infiltrative marrow disease, TAR Increased Destruction • Megaloblastic anemia • Immune • Non-immune • Alloimmune, Autoimmune: ITP, SLE • DIC, TTP, HUS Others • Splenic sequestration • Dilutional • Hypersplenism • Massive blood transfusion
- 28. BLEEDING TIME
- 29. BLEEDING TIME: INTERPRETATION Normal value* : 1-9 min Prolonged bleeding time: Thrombocytopenia/ anemia (hct < 20%) Hereditary platelet dysfunction Von willebrand disease Severe hypofibrinogenemia Blood vessels disorders Uremia Myeloproliferative disorders Medication: aspirin, nsaids,other antiplatelet drugs
- 31. ASSESSMENT OF SECONDARY HEMOSTASIS SCREENING TESTS: PT APTT MIXING STUDY ADDITIONAL TESTS FIBRINOGEN THROMBIN TIME REPTILASE TIME COAGULATION FACTOR ASSAYS D-DIMER FIBRIN DEGRADATION PRODUCT EUGLOBULIN LYSIS TIME
- 32. PROTHROMBIN TIME (PT) PT : test extrinsic and common pathway
- 33. ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) aPTT : test intrinsic and common pathway
- 34. MIXING STUDY + 0% 100% 50% <35% Correctable Normal coagulation time Uncorrectable prolonged coagulation time Deficienc y Inhibit or Prolonged PT or aPTT occurs when coagulation factor < 35- 40%
- 35. INTERPRETATION OF ABNORMAL COAGULOGRAM ISOLATED PROLONGED PT ISOLATED PROLONAGED APTT PROLONGED PT AND APTT
- 36. Isolated prolonged PT Mixing study Correctable Uncorrectable Deficiency Inhibitor Hereditary: FVII FVII (rare) Lupus anticoagulant Acquired: Early liver impairment Vitamin K antagonist Vitamin K deficiency
- 37. Isolated prolonged aPTT Bleeding No bleeding Mixing study Mixing study Correctable Uncorrectable Correctable Uncorrectable Deficiency Inhibitor Deficiency Inhibitor Factor VIII /vWD Factor VIII Factor XII Factor XII Factor IX Factor IX HMWK HMWK Factor XI Factor XI Prekallekrein Prekallekrein Heparin Lupus anticoagulant
- 39. Prolonged aPTT and PT Mixing study Correctable Uncorrectable - FII,FV or FX deficiency - FII, V, or X inhibitor - FV and VIII deficiency - Lupus anticoagulant - Liver disease - LAC + Factor inhibitor - Vitamin K antagonist - Vitamin K deficiency - DIC
- 40. SUMMARY • HISTORY & PHYSICAL EXAMINATION • LABORATORY TESTS • SCREENING TESTS • SPECIFIC DIAGNOSTIC TESTS • DIAGNOSIS-SPECIFIC THERAPY • FACTOR REPLACEMENT • DRUGS
- 41. REFFERENCES • KUMAR • CECIL • WEBSITE