This document provides guidance on evaluating patients presenting with bleeding. It outlines the key phases in how bleeding starts and stops, and important factors to consider in determining the cause. A thorough clinical history and physical exam are most important for accurate diagnosis. Common secondary causes of bleeding should be ruled out before considering rare primary/congenital disorders. Initial screening tests include a full blood count, blood film, bleeding time, APTT, PT and fibrinogen level to identify potential platelet, vascular, or coagulation abnormalities. Further testing may be needed depending on the results and likelihood of an underlying bleeding disorder.
This document discusses the approach to evaluating and treating patients with bleeding disorders. It covers the basics of hemostasis, investigating the cause of bleeding through tests like coagulation studies and mixing tests, and treating bleeding through local measures, replacement therapy using blood components, or bypassing agents. The key is to determine if the bleeding is due to a platelet, vessel, or coagulation factor problem and then target replacement of the deficient component.
A 2-year-old boy presented with swelling and hematoma of the right shoulder after a fall. Laboratory tests found prolonged aPTT and normal platelet count and bleeding time, indicating a factor deficiency in the intrinsic coagulation pathway. The boy's cousin had a similar bleeding problem.
This document summarizes a seminar presentation on approaches to bleeding disorders in pediatric patients. It provides an overview of homeostasis and the blood clotting process, as well as some common bleeding disorders seen in pediatrics. The diagnosis of bleeding disorders involves taking a medical history, performing a physical exam, and conducting laboratory investigations such as platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time to evaluate the platelet count and function, as well as factors in the intrinsic and extrinsic coagulation pathways.
Approach to a bleeding disorder: These presentation has the approach for a patient of bleeding disorder. it has History, physical finding, Investigations.
This document discusses the approach to evaluating and managing a child presenting with a bleeding tendency. Key points include obtaining a thorough history including details of the bleeding, family history of bleeding disorders, and reviewing systems. A full examination focusing on sites of bleeding and developmental milestones is important. Initial investigations would include a CBC, coagulation studies, and bone marrow examination if ITP is suspected. Common causes discussed are immune thrombocytopenia, hemophilia A/B, and von Willebrand disease. Treatment is aimed at the underlying cause and ranges from observation to IVIG, steroids, platelet transfusions, or specialized coagulation factor replacement.
This document provides information about platelet transfusion. It discusses what platelets are, their role in hemostasis, normal platelet counts, causes of thrombocytopenia, indications for platelet transfusion, contraindications, donor criteria, preparation of platelet concentrates, dosing, response to transfusion, complications including immunological and non-immunological issues, and methods to reduce complications like use of leukoreduced products. The document contains detailed information about platelet immunology, causes of refractoriness, its management, and methods to improve safety and availability of platelet transfusion like use of matched donors and crossmatching.
This document discusses normal hemostasis and bleeding disorders. It begins by describing the normal mechanisms of hemostasis, including the primary and secondary stages. It then discusses various bleeding disorders that can result from defects in blood vessels, platelets, or coagulation factors. Common laboratory tests for evaluation of hemostasis are also presented, including prothrombin time, activated partial thromboplastin time, thrombin time, and fibrinogen levels. Interpretation of laboratory findings and secondary tests like mixing studies are outlined. Causes of abnormal bleeding including qualitative and quantitative platelet and coagulation factor disorders are explored.
The document outlines an approach to evaluating and diagnosing bleeding disorders. It discusses:
1. Obtaining a clinical history and performing screening laboratory tests like PT, PTT, and platelet count to classify the bleeding as a platelet, coagulation factor, or other disorder.
2. Using specialized tests like mixing studies and inhibitor assays to identify specific factor deficiencies or inhibitors.
3. Considering rare causes if screening tests are normal, like defects in fibrinolysis or factor XIII.
4. Evaluating acquired bleeding in settings like liver disease and surgery.
A detailed approach with diagnostic algorithms is provided.
This document discusses the approach to evaluating and treating patients with bleeding disorders. It covers the basics of hemostasis, investigating the cause of bleeding through tests like coagulation studies and mixing tests, and treating bleeding through local measures, replacement therapy using blood components, or bypassing agents. The key is to determine if the bleeding is due to a platelet, vessel, or coagulation factor problem and then target replacement of the deficient component.
A 2-year-old boy presented with swelling and hematoma of the right shoulder after a fall. Laboratory tests found prolonged aPTT and normal platelet count and bleeding time, indicating a factor deficiency in the intrinsic coagulation pathway. The boy's cousin had a similar bleeding problem.
This document summarizes a seminar presentation on approaches to bleeding disorders in pediatric patients. It provides an overview of homeostasis and the blood clotting process, as well as some common bleeding disorders seen in pediatrics. The diagnosis of bleeding disorders involves taking a medical history, performing a physical exam, and conducting laboratory investigations such as platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time to evaluate the platelet count and function, as well as factors in the intrinsic and extrinsic coagulation pathways.
Approach to a bleeding disorder: These presentation has the approach for a patient of bleeding disorder. it has History, physical finding, Investigations.
This document discusses the approach to evaluating and managing a child presenting with a bleeding tendency. Key points include obtaining a thorough history including details of the bleeding, family history of bleeding disorders, and reviewing systems. A full examination focusing on sites of bleeding and developmental milestones is important. Initial investigations would include a CBC, coagulation studies, and bone marrow examination if ITP is suspected. Common causes discussed are immune thrombocytopenia, hemophilia A/B, and von Willebrand disease. Treatment is aimed at the underlying cause and ranges from observation to IVIG, steroids, platelet transfusions, or specialized coagulation factor replacement.
This document provides information about platelet transfusion. It discusses what platelets are, their role in hemostasis, normal platelet counts, causes of thrombocytopenia, indications for platelet transfusion, contraindications, donor criteria, preparation of platelet concentrates, dosing, response to transfusion, complications including immunological and non-immunological issues, and methods to reduce complications like use of leukoreduced products. The document contains detailed information about platelet immunology, causes of refractoriness, its management, and methods to improve safety and availability of platelet transfusion like use of matched donors and crossmatching.
This document discusses normal hemostasis and bleeding disorders. It begins by describing the normal mechanisms of hemostasis, including the primary and secondary stages. It then discusses various bleeding disorders that can result from defects in blood vessels, platelets, or coagulation factors. Common laboratory tests for evaluation of hemostasis are also presented, including prothrombin time, activated partial thromboplastin time, thrombin time, and fibrinogen levels. Interpretation of laboratory findings and secondary tests like mixing studies are outlined. Causes of abnormal bleeding including qualitative and quantitative platelet and coagulation factor disorders are explored.
The document outlines an approach to evaluating and diagnosing bleeding disorders. It discusses:
1. Obtaining a clinical history and performing screening laboratory tests like PT, PTT, and platelet count to classify the bleeding as a platelet, coagulation factor, or other disorder.
2. Using specialized tests like mixing studies and inhibitor assays to identify specific factor deficiencies or inhibitors.
3. Considering rare causes if screening tests are normal, like defects in fibrinolysis or factor XIII.
4. Evaluating acquired bleeding in settings like liver disease and surgery.
A detailed approach with diagnostic algorithms is provided.
Coagulation factor disorders like hemophilia A and B cause prolonged PT or PTT and bleeding. They are treated with replacement factors or adjuvant drugs.
Platelet disorders can be quantitative or qualitative and cause petechiae or mucocutaneous bleeding. Treatment involves platelet transfusion.
Adjuvant drugs like aminocaproic acid, DDAVP, fresh frozen plasma, cryoprecipitate, and recombinant factor VIIa can help treat bleeding from various coagulation disorders.
Approach to a child with bleeding for UGsCSN Vittal
This document discusses hemostasis and bleeding disorders. It covers platelet disorders, coagulation factor deficiencies, and vascular disorders that can cause bleeding. Evaluation of bleeding disorders includes obtaining a medical history, physical examination, and laboratory tests like platelet count, bleeding time, prothrombin time, and factor assays. Specific disorders discussed include hemophilia A, hemophilia B, and von Willebrand disease. Treatment involves replacing the deficient clotting factor through blood component transfusion or recombinant factor replacement.
The patient, a 10-year-old boy, presented with pain, swelling and reduced movement of both elbows and bruises on his knees, and has a history of hemophilia A diagnosed at age 1. Examination found swollen and warm elbows with restricted range of motion, and bruises on the knees. He was treated with factor VIII replacement therapy over 5 days which improved the right elbow but the left elbow still had some restriction.
Fresh frozen plasma (FFP) is the fluid portion of blood that has been separated, frozen, and can be stored at -18C for up to 24 months. It contains coagulation factors and proteins. FFP is administered to treat deficiencies of coagulation factors II, V, VII, IX, X, and XI when specific therapies are unavailable. It is also used to reverse the effects of warfarin anticoagulation in patients who are actively bleeding. Potential adverse effects include disease transmission, allergic reactions, alloimmunization, and transfusion-related lung injury.
Approach to the adult with bleeding disorderAli S. Mayali
The normal clotting process involves platelets and coagulation factors working together to form a clot and stop bleeding. Platelets initially aggregate at the site of injury and release substances to enhance clotting. Coagulation factors are then activated through initiation and amplification pathways, leading to thrombin generation and fibrin strand formation to stabilize the clot. Bleeding disorders can occur if there are deficiencies or dysfunctions of platelets, coagulation factors, or excessive fibrinolysis. Laboratory tests including platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time are used to evaluate the hemostatic system and identify the cause of bleeding disorders.
This document discusses idiopathic thrombocytopenic purpura (ITP), now called immune thrombocytopenic purpura. ITP is an autoimmune disorder where the immune system mistakenly destroys platelets. There are two types: acute ITP typically affects young children and often resolves on its own, while chronic ITP affects older females and symptoms include excessive bleeding. Diagnosis involves low platelet counts and no single confirmatory test. Treatment focuses on corticosteroids, splenectomy to remove the spleen which produces antibodies, or IV immunoglobulin for emergency cases.
Approach to bleeding disorder (coagulation defects) in childrenSatish Vadapalli
1. Unprovoked hemarthroses and muscle hemorrhages suggest one of the hemophilias, while mucocutaneous bleeding is more characteristic of platelet disorders, thrombocytopenia, or von Willebrand disease.
2. Epistaxis is a common symptom of platelet disorders, von Willebrand disease, and hereditary hemorrhagic telangiectasia. Gingival hemorrhage is very common in patients with qualitative and quantitative platelet abnormalities and von Willebrand disease.
3. Excessive bleeding or bruising is difficult to define objectively, and responses to questions about bruising vary significantly between men and women. Objective data, like previous transfusions or need for packing
This document discusses bleeding disorders and provides details on specific disorders such as von Willebrand disease, hemophilia, and immune thrombocytopenia. It describes the pathophysiology of hemostasis and the coagulation cascade. Signs and symptoms of bleeding disorders are outlined depending on whether they affect the primary or secondary phase of hemostasis. The diagnostic approach and differential diagnosis for evaluating bleeding disorders is also summarized.
Idiopathic thrombocytopenic purpura (ITP) is a bleeding disorder caused by the immune-mediated destruction of platelets. It most commonly presents in children between 1-7 years of age, usually after a viral infection. ITP results in low platelet counts and spontaneous bruising or bleeding. Diagnosis involves low platelet count, absence of other abnormalities, and normal bone marrow with increased or normal megakaryocytes. Treatment depends on if it is acute or chronic ITP, and may include corticosteroids, IVIG, anti-D immunoglobulin, thrombopoietin receptor agonists, or splenectomy in severe cases.
This document provides information on the definition, presentation, evaluation, investigation and treatment of anemia. It defines anemia as a hemoglobin level below certain thresholds based on sex. Anemia is often identified through screening tests but can sometimes present with symptoms of advanced anemia. Evaluation involves taking a medical history and performing a physical exam and blood tests. Based on test results, anemias are classified and specific treatment is given depending on the underlying cause, such as iron supplementation for iron deficiency anemia or blood transfusions for acute blood loss.
Hemophilia is a hereditary bleeding disorder caused by a deficiency of specific clotting factors, which prevents normal blood clotting. The two main types are hemophilia A caused by a factor VIII deficiency and hemophilia B caused by a factor IX deficiency. Symptoms include excessive bleeding, easy bruising, and bleeding into joints. It is usually passed from mother to son and is treated through replacement of the deficient clotting factor. Nursing care focuses on prevention of injury, control of bleeding episodes, and prevention of joint damage.
This document discusses various disorders of coagulation and hemostasis. It describes the normal physiologic mechanisms of hemostasis, coagulation pathways, and fibrinolysis. It then discusses several specific bleeding disorders including von Willebrand disease, hemophilia, disseminated intravascular coagulation (DIC), thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenic purpura (ITP), and qualitative platelet defects. Laboratory tests used to evaluate coagulation and bleeding disorders are also outlined.
The seminar presentation covered hemostasis and approaches to bleeding disorders in pediatrics. It discussed the pathophysiology, clinical features, laboratory findings and management of idiopathic thrombocytopenic purpura, Von Willebrand's disease, and hemophilia. It provided an overview of hemostasis and the coagulation cascade, approaches to evaluating a child with bleeding, and specifics on selected bleeding disorders. The presentation included descriptions of laboratory tests used to evaluate coagulation factors and identify bleeding disorders.
The document discusses several potential complications of blood transfusion:
1) The most common complications are febrile nonhemolytic and chill-rigor reactions. The most serious complications are acute hemolytic reactions and transfusion-related acute lung injury, which have high mortality rates.
2) If any symptoms of a transfusion reaction occur, such as chills, fever, or breathing problems, the transfusion must be stopped immediately and investigated.
3) Delayed hemolytic reactions can occur 1-4 weeks after transfusion if a patient has low antibody levels not detected on pretransfusion tests.
A patient has a history of recurrent gum bleeding since childhood. While platelet counts and coagulation tests are normal, an inherited platelet disorder is suspected. The doctor's diagnostic approach would include a detailed bleeding history, physical exam looking for bruises/petechiae, and first-line screening tests like a bleeding time and platelet function analyzer. Further specific tests may include light transmission aggregometry to assess platelet aggregation in response to various agonists and help identify potential defects in adhesion, activation, secretion or aggregation. Interpreting the different waveforms is important to determine abnormalities consistent with disorders like Glanzmann's thrombasthenia or storage pool disease.
The document summarizes several cases of hypercoagulable states and deep vein thrombosis (DVT). It describes three cases: 1) A 36-year-old with recurrent DVT who presented with abdominal pain and bleeding, 2) A 33-year-old man with sudden dyspnea and chest pain along with leg edema, and 3) A 21-year-old woman referred for contraceptive evaluation given her family history of thrombosis. It then reviews hypercoagulable states, including definitions and classifications of congenital and acquired causes. Specific conditions discussed in detail include deficiencies of antithrombin, protein C, and protein S; factor V Leiden; prothrombin gene mutation; antiphosph
Blood transfusion reactions and complicationsSCGH ED CME
1. A 68-year-old woman with a background of chronic myeloid leukemia presented to the emergency department with respiratory distress and fever after receiving a blood transfusion.
2. She was found to have a fever, low oxygen saturation, rapid breathing, and rapid heart rate, suggesting a potential transfusion reaction.
3. Initial management involved stopping the transfusion, monitoring vital signs, and performing investigations to identify the type of reaction and guide further treatment. Prevention of transfusion reactions is important through proper patient identification, following protocols, and identifying high-risk groups.
1. Anemia can be classified based on MCV as microcytic, normocytic, or macrocytic. Laboratory data and physical exam findings help determine the underlying cause.
2. Automated hematology analyzers use electrical impedance and light scattering to count and characterize blood cells from a sample. This provides rapid results but still requires confirming abnormal findings on a peripheral smear.
3. A thorough history, physical exam, and initial lab work can help establish a differential diagnosis and guide further testing for a patient presenting with anemia.
Approach to patients with bleeding disordersAYM NAZIM
This document provides an overview of haemostasis and bleeding disorders. It defines haemostasis and its normal mechanism, then discusses the haemostatic system components and their role in haemostasis and thrombosis prevention. It describes different types of haemorrhagic disorders including those due to vascular defects, platelet abnormalities, coagulation factor deficiencies, and disseminated intravascular coagulation. Specific bleeding disorders like thrombocytopenia, immune thrombocytopenic purpura, hemophilia, and thrombotic thrombocytopenic purpura are also summarized.
Laboratory tests of hemostasis and coagulation systemderosaMSKCC
This document discusses thrombophilia testing and risk factors for thrombosis. It describes Virchow's triad of factors that can lead to thrombosis, including changes in blood flow, endothelial injury, and hypercoagulability. Both congenital and acquired risk factors are discussed, including deficiencies in natural anticoagulants like protein C, protein S, and antithrombin. Assays used to test for these deficiencies, like functional, antigenic, and DNA-based assays, are outlined. The roles of the laboratory and physician in thrombophilia testing are also summarized.
Coagulation factor disorders like hemophilia A and B cause prolonged PT or PTT and bleeding. They are treated with replacement factors or adjuvant drugs.
Platelet disorders can be quantitative or qualitative and cause petechiae or mucocutaneous bleeding. Treatment involves platelet transfusion.
Adjuvant drugs like aminocaproic acid, DDAVP, fresh frozen plasma, cryoprecipitate, and recombinant factor VIIa can help treat bleeding from various coagulation disorders.
Approach to a child with bleeding for UGsCSN Vittal
This document discusses hemostasis and bleeding disorders. It covers platelet disorders, coagulation factor deficiencies, and vascular disorders that can cause bleeding. Evaluation of bleeding disorders includes obtaining a medical history, physical examination, and laboratory tests like platelet count, bleeding time, prothrombin time, and factor assays. Specific disorders discussed include hemophilia A, hemophilia B, and von Willebrand disease. Treatment involves replacing the deficient clotting factor through blood component transfusion or recombinant factor replacement.
The patient, a 10-year-old boy, presented with pain, swelling and reduced movement of both elbows and bruises on his knees, and has a history of hemophilia A diagnosed at age 1. Examination found swollen and warm elbows with restricted range of motion, and bruises on the knees. He was treated with factor VIII replacement therapy over 5 days which improved the right elbow but the left elbow still had some restriction.
Fresh frozen plasma (FFP) is the fluid portion of blood that has been separated, frozen, and can be stored at -18C for up to 24 months. It contains coagulation factors and proteins. FFP is administered to treat deficiencies of coagulation factors II, V, VII, IX, X, and XI when specific therapies are unavailable. It is also used to reverse the effects of warfarin anticoagulation in patients who are actively bleeding. Potential adverse effects include disease transmission, allergic reactions, alloimmunization, and transfusion-related lung injury.
Approach to the adult with bleeding disorderAli S. Mayali
The normal clotting process involves platelets and coagulation factors working together to form a clot and stop bleeding. Platelets initially aggregate at the site of injury and release substances to enhance clotting. Coagulation factors are then activated through initiation and amplification pathways, leading to thrombin generation and fibrin strand formation to stabilize the clot. Bleeding disorders can occur if there are deficiencies or dysfunctions of platelets, coagulation factors, or excessive fibrinolysis. Laboratory tests including platelet count, bleeding time, prothrombin time, activated partial thromboplastin time, and thrombin time are used to evaluate the hemostatic system and identify the cause of bleeding disorders.
This document discusses idiopathic thrombocytopenic purpura (ITP), now called immune thrombocytopenic purpura. ITP is an autoimmune disorder where the immune system mistakenly destroys platelets. There are two types: acute ITP typically affects young children and often resolves on its own, while chronic ITP affects older females and symptoms include excessive bleeding. Diagnosis involves low platelet counts and no single confirmatory test. Treatment focuses on corticosteroids, splenectomy to remove the spleen which produces antibodies, or IV immunoglobulin for emergency cases.
Approach to bleeding disorder (coagulation defects) in childrenSatish Vadapalli
1. Unprovoked hemarthroses and muscle hemorrhages suggest one of the hemophilias, while mucocutaneous bleeding is more characteristic of platelet disorders, thrombocytopenia, or von Willebrand disease.
2. Epistaxis is a common symptom of platelet disorders, von Willebrand disease, and hereditary hemorrhagic telangiectasia. Gingival hemorrhage is very common in patients with qualitative and quantitative platelet abnormalities and von Willebrand disease.
3. Excessive bleeding or bruising is difficult to define objectively, and responses to questions about bruising vary significantly between men and women. Objective data, like previous transfusions or need for packing
This document discusses bleeding disorders and provides details on specific disorders such as von Willebrand disease, hemophilia, and immune thrombocytopenia. It describes the pathophysiology of hemostasis and the coagulation cascade. Signs and symptoms of bleeding disorders are outlined depending on whether they affect the primary or secondary phase of hemostasis. The diagnostic approach and differential diagnosis for evaluating bleeding disorders is also summarized.
Idiopathic thrombocytopenic purpura (ITP) is a bleeding disorder caused by the immune-mediated destruction of platelets. It most commonly presents in children between 1-7 years of age, usually after a viral infection. ITP results in low platelet counts and spontaneous bruising or bleeding. Diagnosis involves low platelet count, absence of other abnormalities, and normal bone marrow with increased or normal megakaryocytes. Treatment depends on if it is acute or chronic ITP, and may include corticosteroids, IVIG, anti-D immunoglobulin, thrombopoietin receptor agonists, or splenectomy in severe cases.
This document provides information on the definition, presentation, evaluation, investigation and treatment of anemia. It defines anemia as a hemoglobin level below certain thresholds based on sex. Anemia is often identified through screening tests but can sometimes present with symptoms of advanced anemia. Evaluation involves taking a medical history and performing a physical exam and blood tests. Based on test results, anemias are classified and specific treatment is given depending on the underlying cause, such as iron supplementation for iron deficiency anemia or blood transfusions for acute blood loss.
Hemophilia is a hereditary bleeding disorder caused by a deficiency of specific clotting factors, which prevents normal blood clotting. The two main types are hemophilia A caused by a factor VIII deficiency and hemophilia B caused by a factor IX deficiency. Symptoms include excessive bleeding, easy bruising, and bleeding into joints. It is usually passed from mother to son and is treated through replacement of the deficient clotting factor. Nursing care focuses on prevention of injury, control of bleeding episodes, and prevention of joint damage.
This document discusses various disorders of coagulation and hemostasis. It describes the normal physiologic mechanisms of hemostasis, coagulation pathways, and fibrinolysis. It then discusses several specific bleeding disorders including von Willebrand disease, hemophilia, disseminated intravascular coagulation (DIC), thrombotic thrombocytopenic purpura (TTP), immune thrombocytopenic purpura (ITP), and qualitative platelet defects. Laboratory tests used to evaluate coagulation and bleeding disorders are also outlined.
The seminar presentation covered hemostasis and approaches to bleeding disorders in pediatrics. It discussed the pathophysiology, clinical features, laboratory findings and management of idiopathic thrombocytopenic purpura, Von Willebrand's disease, and hemophilia. It provided an overview of hemostasis and the coagulation cascade, approaches to evaluating a child with bleeding, and specifics on selected bleeding disorders. The presentation included descriptions of laboratory tests used to evaluate coagulation factors and identify bleeding disorders.
The document discusses several potential complications of blood transfusion:
1) The most common complications are febrile nonhemolytic and chill-rigor reactions. The most serious complications are acute hemolytic reactions and transfusion-related acute lung injury, which have high mortality rates.
2) If any symptoms of a transfusion reaction occur, such as chills, fever, or breathing problems, the transfusion must be stopped immediately and investigated.
3) Delayed hemolytic reactions can occur 1-4 weeks after transfusion if a patient has low antibody levels not detected on pretransfusion tests.
A patient has a history of recurrent gum bleeding since childhood. While platelet counts and coagulation tests are normal, an inherited platelet disorder is suspected. The doctor's diagnostic approach would include a detailed bleeding history, physical exam looking for bruises/petechiae, and first-line screening tests like a bleeding time and platelet function analyzer. Further specific tests may include light transmission aggregometry to assess platelet aggregation in response to various agonists and help identify potential defects in adhesion, activation, secretion or aggregation. Interpreting the different waveforms is important to determine abnormalities consistent with disorders like Glanzmann's thrombasthenia or storage pool disease.
The document summarizes several cases of hypercoagulable states and deep vein thrombosis (DVT). It describes three cases: 1) A 36-year-old with recurrent DVT who presented with abdominal pain and bleeding, 2) A 33-year-old man with sudden dyspnea and chest pain along with leg edema, and 3) A 21-year-old woman referred for contraceptive evaluation given her family history of thrombosis. It then reviews hypercoagulable states, including definitions and classifications of congenital and acquired causes. Specific conditions discussed in detail include deficiencies of antithrombin, protein C, and protein S; factor V Leiden; prothrombin gene mutation; antiphosph
Blood transfusion reactions and complicationsSCGH ED CME
1. A 68-year-old woman with a background of chronic myeloid leukemia presented to the emergency department with respiratory distress and fever after receiving a blood transfusion.
2. She was found to have a fever, low oxygen saturation, rapid breathing, and rapid heart rate, suggesting a potential transfusion reaction.
3. Initial management involved stopping the transfusion, monitoring vital signs, and performing investigations to identify the type of reaction and guide further treatment. Prevention of transfusion reactions is important through proper patient identification, following protocols, and identifying high-risk groups.
1. Anemia can be classified based on MCV as microcytic, normocytic, or macrocytic. Laboratory data and physical exam findings help determine the underlying cause.
2. Automated hematology analyzers use electrical impedance and light scattering to count and characterize blood cells from a sample. This provides rapid results but still requires confirming abnormal findings on a peripheral smear.
3. A thorough history, physical exam, and initial lab work can help establish a differential diagnosis and guide further testing for a patient presenting with anemia.
Approach to patients with bleeding disordersAYM NAZIM
This document provides an overview of haemostasis and bleeding disorders. It defines haemostasis and its normal mechanism, then discusses the haemostatic system components and their role in haemostasis and thrombosis prevention. It describes different types of haemorrhagic disorders including those due to vascular defects, platelet abnormalities, coagulation factor deficiencies, and disseminated intravascular coagulation. Specific bleeding disorders like thrombocytopenia, immune thrombocytopenic purpura, hemophilia, and thrombotic thrombocytopenic purpura are also summarized.
Laboratory tests of hemostasis and coagulation systemderosaMSKCC
This document discusses thrombophilia testing and risk factors for thrombosis. It describes Virchow's triad of factors that can lead to thrombosis, including changes in blood flow, endothelial injury, and hypercoagulability. Both congenital and acquired risk factors are discussed, including deficiencies in natural anticoagulants like protein C, protein S, and antithrombin. Assays used to test for these deficiencies, like functional, antigenic, and DNA-based assays, are outlined. The roles of the laboratory and physician in thrombophilia testing are also summarized.
The bleeding time test measures the time it takes for a small puncture wound to stop bleeding. It evaluates platelet function and vascular integrity. The preferred method is the Surgicutt/Simplate method, which uses a spring-loaded device to make a standardized 1mm deep incision. The procedure involves inflating a blood pressure cuff to 40mmHg, making the incision, and blotting the wound every 30 seconds with filter paper to see when bleeding stops. The normal bleeding time range is 1-9 minutes. Sources of error include aspirin use, improper puncture technique, not timing correctly, or allowing the filter paper to touch the wound.
The document discusses tests used to evaluate bleeding disorders. It begins by describing normal hemostasis and the role of platelets and coagulation factors. It then discusses specific bleeding disorders that can result from platelet defects, coagulation factor deficiencies, or fragile blood vessels. The document outlines several laboratory tests used to evaluate hemostasis, including bleeding time, clotting time, platelet count, prothrombin time, activated partial thromboplastin time, thrombin time, and capillary fragility test. Each test is described in terms of its methodology, what coagulation or platelet pathways it evaluates, and how results are interpreted to identify potential causes of bleeding disorders.
This document summarizes various inherited and acquired bleeding disorders:
1. It describes disorders of blood coagulation including hemophilia A and B due to factor VIII and IX deficiencies, von Willebrand disease, and liver disease-related deficiencies.
2. Common tests used to evaluate hemostasis such as PT, PTT, bleeding time, and factor assays are outlined.
3. Causes of abnormal coagulation test results and approaches to initial evaluation of a bleeding patient are provided.
The document discusses coagulation testing, including bleeding time, clotting time, prothrombin time (PT), and partial thromboplastin time (PTT). It provides details on each test, including what they measure, normal ranges, and implications of abnormal results. Prolonged PT can indicate deficiencies in factors of the extrinsic pathway, while prolonged PTT suggests deficiencies in the intrinsic pathway or use of anticoagulants like heparin. Inherited bleeding disorders like hemophilia A and B and von Willebrand disease can also prolong test times.
This document discusses hemostasis, bleeding disorders, and platelet disorders. It begins by explaining normal hemostasis and the mechanisms involved in maintaining a fluid blood state and forming clots at sites of injury. It then defines bleeding disorders as problems with blood clotting that result in abnormal bleeding. Common causes discussed include defects in blood vessels or blood itself, clotting factor deficiencies, platelet abnormalities, and liver disease. Finally, it examines several specific platelet disorders like thrombocytopenia, immune thrombocytopenic purpura, hemolytic uremic syndrome, thrombotic thrombocytopenic purpura, and those resulting from bone marrow infiltration or disseminated intravascular coagulation.
Investigations for childhood bleeding disorder Amena Yasmin
This document discusses the evaluation of patients presenting with symptoms of a bleeding disorder. It involves taking a thorough history, physical examination, and laboratory tests. The history focuses on sites of bleeding, family history of bleeding disorders, medical history, and determining if the condition is genetic. The physical exam checks for bruising, signs of anemia or liver/spleen issues. Screening tests include a full blood count, platelet count, bleeding time, aPTT, PT, and fibrinogen levels. Specific tests can identify factor deficiencies, von Willebrand disease, liver disease, vitamin deficiencies, or the presence of inhibitors. Genetic screening may also be used to diagnose the underlying cause.
This document discusses various bleeding disorders including:
- Definition as a disorder characterized by spontaneous or excessive bleeding following trauma.
- Etiologies including vessel wall abnormalities (congenital or acquired like vasculitis) and platelet functional disorders.
- Specific disorders discussed in more detail include von Willebrand disease, hemophilia, Bernard-Soulier syndrome, and Glanzmann's thrombasthenia.
- Clinical features, laboratory findings, and treatment approaches are provided for many of the disorders.
This document discusses various bleeding disorders including definitions, etiologies, and clinical features. It covers vessel wall abnormalities like hereditary hemorrhagic telangiectasia and Ehlers Danlos disease. Platelet disorders discussed include quantitative issues like thrombocytopenia and qualitative issues such as Bernard Soulier syndrome. Coagulation disorders covered include hemophilia A, hemophilia B, and acquired disorders like disseminated intravascular coagulation and liver disease. Specific conditions like idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, and von Willebrand disease are explained in detail.
Laboratory tests play an important role in diagnosing, monitoring, and treating coagulation disorders. Common tests include activated prothrombin time (aPT), activated partial thromboplastin time (aPTT), thrombin time, and bleeding time. These tests help identify factor deficiencies, monitor anticoagulation therapy, and provide sensitivity when the clinical picture is known. Proper interpretation requires understanding how the tests are performed and their limitations.
0.3 % MCHC 31.7 g/dL
BASO 0.5 % RDW 13.2 %
PLT <10 K/μL
Questions:
1. What is abnormal about her CBC?
2. What procedures can be done regarding the abnormal result?
Answers:
1. The platelet count is less than 10 K/μL, indicating thrombocytopenia.
2. To determine the cause of thrombocytopenia:
- Review the patient's history for possible causes such as medications, recent viral illness, bleeding, pregnancy, etc.
- Perform a peripheral blood smear examination to check
Laboratory tests of hemostasis and coagulation system (dr ellinor peerschke ...derosaMSKCC
This document provides an introduction to coagulation testing, including preanalytical and analytical variables. It discusses specimen collection and processing, common coagulation assays, and how to interpret their results. Prolonged screening tests can indicate factor deficiencies or circulating anticoagulants like lupus anticoagulant, requiring additional studies. New direct oral anticoagulants affect clot-based assays in a concentration-dependent manner. D-dimer assays are used to evaluate for fibrinolysis or thrombosis. HIT testing involves screening ELISA to detect heparin-PF4 antibodies followed by confirmatory assays if needed.
1) Hemostasis involves both primary and secondary processes to stop bleeding after vessel injury. Primary hemostasis involves platelet plug formation while secondary hemostasis involves a coagulation cascade leading to fibrin clot formation.
2) The coagulation cascade occurs through the intrinsic and extrinsic pathways which converge at the activation of factor X and ultimately lead to the formation of thrombin. Thrombin then converts fibrinogen to fibrin to form a stable clot.
3) Careful regulation is needed as too much coagulation can cause thrombosis while inadequate coagulation can cause bleeding. The vascular endothelium plays a key role through secretion of both pro- and anti-coagulant factors.
[Int. med] bleeding disorders from SIMS LahoreMuhammad Ahmad
This document discusses bleeding and clotting disorders. It provides details on:
1. The normal physiology of hemostasis including vascular, platelet and plasma factors that prevent bleeding.
2. Specific platelet and plasma factor deficiencies that can cause bleeding disorders.
3. The classification of bleeding disorders into defects of blood vessels, platelet disorders, and clotting factor deficiencies.
4. Diagnostic tests for evaluating bleeding patients including screening coagulation tests, specific factor assays, and platelet function tests.
The document summarizes the process of hemostasis (prevention of blood loss after injury) which involves vascular constriction, platelet plug formation, and coagulation. It describes the roles of platelets, coagulation factors, fibrinolysis, and endothelial cells in hemostasis and thrombosis. Abnormalities that can cause bleeding disorders or thrombosis are also listed.
The document provides an overview and learning module on coagulation and hemostasis created by a medical student at the University of Vermont College of Medicine. It begins with definitions of key terms and an overview of primary and secondary hemostasis. It then reviews the components of the coagulation cascade including the extrinsic, intrinsic, and common pathways. It discusses pharmacologic considerations and the roles of the endothelium and subendothelium. Finally, it provides a detailed review of coagulation and hemostasis in a series of slides for students to test their knowledge.
A presentation made by Dr Gauhar Mahmood Azeem on the interpretations of a simple CBC and the information it can give us, Various conditions which may cause derangement are mentioned,
This document summarizes drugs used to treat three blood dysfunctions: thrombosis, bleeding, and anemia. It discusses anticoagulant and thrombolytic drugs used to treat thrombosis. Anticoagulants like heparin and warfarin prevent clotting through different mechanisms. Heparin enhances antithrombin inhibition of coagulation factors. Warfarin inhibits vitamin K-dependent clotting factor synthesis. Thrombolytics like plasmin dissolve clots by activating plasminogen. The document also covers the mechanisms, uses, and toxicities of various anticoagulant and thrombolytic drugs.
This document discusses the approach to evaluating and treating bleeding in children. It covers the physiology of hemostasis, clinical evaluation, hereditary and acquired bleeding disorders like hemophilia A/B and von Willebrand disease, and platelet disorders. Specific case scenarios are presented to demonstrate how different bleeding patterns and test results can help diagnose conditions like hemophilia or platelet function defects. The role of factor replacement therapies, desmopressin, and other treatments are also summarized.
This document discusses the approach to disorders of bleeding and thrombosis. It covers the main components of hemostasis including the vascular endothelium, platelets, coagulation system, and fibrinolysis. It then discusses specific factors, disorders, investigations, and treatments related to bleeding and thrombotic disorders. The key points are that a thorough history, examination, and screening coagulation tests are needed to evaluate a patient. Additional targeted tests may be needed to identify the underlying cause, which could include a deficiency or inhibitor. Treatment depends on the specific disorder diagnosed.
The document discusses hemostasis and its main components: the vascular endothelium, platelets, coagulation system, and fibrinolysis. It describes how the endothelium normally prevents clotting but can promote it, and the roles of von Willebrand factor, platelets, and coagulation factors. Key factors preventing coagulation are also outlined. The extension of clots is controlled by fibrinolysis and its regulating factors. Thrombotic disorders and their causes are examined, along with risks factors, effects, and approaches to arterial and venous thrombosis patients.
This document discusses haemostasis and bleeding disorders. It covers the basics of haemostasis including primary and secondary phases. It describes taking a bleeding history including duration, site, precipitating factors and family history. Physical examination focuses on sites of bleeding. Investigations start with a platelet count and assessment of bleeding time followed by screening coagulation tests. Based on screening test results, further specific factor assays may be done. Treatment depends on the underlying cause and may include transfusions of specific clotting factors, platelets, cryoprecipitate or non-transfusional options like vitamins, desmopressin or antifibrinolytics.
This document provides information on deep vein thrombosis (DVT), including its definition, risk factors, diagnosis, and treatment. Some key points:
- DVT is a blood clot (thrombus) that forms in a deep vein, usually in the legs. It can dislodge and cause a pulmonary embolism if it reaches the lungs.
- Risk factors for DVT include immobility, surgery, older age, and genetic or acquired hypercoagulable states. The Virchow's triad of factors contributing to clot formation are venous stasis, endothelial injury, and hypercoagulability.
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Deep Vein Thrombosis and Pulmonary Embolism, by Prof. Minnu M. PanditraoMinnu Panditrao
Dr. Mrs. Minnu Panditrao, goes in depth with the very important topic of Deep Vein Thrombosis, Pulmonary embolism, aetio patheogenesis, clinical features, management etc.
Its a elaborate presentation on deep vein thrombosis by surgery resident.
Inform me if any thing needed to be correction.
thank you.
Dr Syed Aftub Uddin, MBBS,CCCD, MS ( Resident)
email: aftub_16@yahoo.com
Surgical hemostasis is one of the pillars of modern surgery. Adequate hemostasis in a surgical patient involves a detailed perioperative clinical evaluation and investigation, and various intra operative techniques and options. Ensuring adequate surgical hemostasis reduces morbidity and mortality by modulating the metabolic response to trauma, decreasing the incidence of post operative anemia, reduces rates of surgical site infection and ultimately improving wound healing
DVT refers to deep vein thrombosis, or a blood clot in the deep veins usually of the legs. It is a common complication after orthopedic surgeries due to immobility and direct manipulation of veins. Diagnosis involves tests like ultrasound, CT, or MRI. Risk factors include immobilization, endothelial injury, and hypercoagulability. Treatment involves anticoagulation drugs or thrombolysis to prevent pulmonary embolism. Prophylaxis includes early mobilization, compression stockings, and anticoagulants. Combined prophylaxis is most effective at preventing DVT and PE after orthopedic surgeries.
A 6-year-old boy presented with recurrent painful swelling of the left knee joint since age 2 and a history of prolonged bleeding from cuts. On examination, his left knee was swollen and tender. Laboratory tests showed a normal prothrombin time but elevated activated partial thromboplastin time that corrected with factor IX-deficient plasma, confirming a diagnosis of hemophilia B. The boy was advised to receive factor IX replacement therapy if he required a dental tooth extraction to prevent uncontrolled bleeding.
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This document provides guidance on evaluating and treating children with bleeding disorders. It outlines the key steps in the clinical approach: obtaining a medical history, conducting a physical exam, and ordering laboratory tests. Common inherited disorders include hemophilia A/B and von Willebrand disease, while acquired disorders include DIC and vitamin K deficiency. Based on the history and exam findings, specific laboratory tests are interpreted to identify coagulation factor deficiencies or other causes of bleeding. Common treatments target the underlying disorder, such as intravenous immunoglobulins for ITP or DDAVP for von Willebrand disease.
Approach to a child with bleeding disorderNehal Shah
This document provides guidance on evaluating and treating bleeding disorders in children. The evaluation involves obtaining a detailed history of the bleeding episodes, family history of bleeding disorders, and a physical exam to identify signs of bleeding. Initial laboratory tests include a complete blood count, bleeding time, prothrombin time, activated partial thromboplastin time, and tests of individual coagulation factors. Specific bleeding disorders are identified based on abnormalities in coagulation factor levels or function. Treatment depends on the underlying cause, and may include medications, coagulation factor replacement, platelet transfusions, or steroids.
This document provides an overview of deep vein thrombosis (DVT). It defines DVT as a blood clot forming in the deep veins of the legs or pelvis. The document outlines key aspects of DVT including epidemiology, anatomy, pathophysiology, risk factors, diagnosis, management, and complications. Diagnosis involves imaging tests like ultrasound and assessment of clinical prediction rules like the Wells criteria. Treatment aims to prevent dangerous complications such as pulmonary embolism, while management seeks to reduce long-term issues like post-thrombotic syndrome.
DVT refers to deep vein thrombosis, which is the formation of a blood clot in the deep veins, usually of the legs. Risk factors include age, immobilization, pregnancy, surgery, cancer and genetic factors. Symptoms include leg swelling, pain, redness and tenderness. Diagnosis involves a clinical probability assessment, D-dimer testing and duplex ultrasonography. Treatment includes anticoagulation medications and compression stockings to prevent complications like pulmonary embolism and post-thrombotic syndrome.
The document provides information on deep vein thrombosis and pulmonary embolism. It discusses:
1. The coagulation process and how abnormalities in the vessel wall, blood flow, or blood components can lead to thrombosis according to Virchow's triad.
2. Risk factors for deep vein thrombosis and pulmonary embolism such as age, cancer, immobilization, and inherited conditions.
3. Diagnostic tests for pulmonary embolism including the Wells criteria for estimating probability, imaging tests like CT scans, and their limitations. Treatment involves anticoagulants like heparin or warfarin.
This document provides guidance on evaluating and categorizing thrombocytopenia in hospitalized patients. It defines thrombocytopenia as a platelet count below 150,000/mL and discusses the life cycle of platelets. Thrombocytopenia can be categorized as pseudothrombocytopenia, decreased production, increased destruction, consumption, or sequestration. A detailed history and physical exam are important for determining the cause. Initial testing should include a CBC, peripheral smear, and tests for HIV and hepatitis C. Common causes of drug-induced thrombocytopenia include antibiotics and heparin.
Congenital Heart Disease is present in approximately 0.8% of children. It is commonly divided into cyanotic and noncyanotic categories based on the direction of blood flow. Tetralogy of Fallot is the most common cyanotic congenital heart defect, characterized by four anatomical abnormalities that result in deoxygenated blood mixing with oxygenated blood. Clinical features include progressive cyanosis after infancy and hypoxic spells in young children. Surgical repair is usually required. Atrial septal defect is a common noncyanotic defect where a hole exists between the upper chambers of the heart. It often causes no symptoms and may close on its own, but larger defects require closure to prevent lung and heart damage.
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This document discusses deep vein thrombosis (DVT), its causes, diagnosis, and treatment. DVT is a clinical entity that can be lethal or recurrent. It occurs in both hospitalized and non-hospitalized patients and can lead to long-term complications like pulmonary hypertension or post-thrombotic syndrome. DVT is diagnosed using tools like ultrasound, MRI, CT scans, or venography. Treatment involves anticoagulation to prevent pulmonary embolism and further complications. The duration of anticoagulation treatment depends on individual risk factors for recurrence.
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Rational approach to evaluate a bleeding patient 2014
1. Rational approach to evaluate a bleeding patient
Dr. Thanuja Dissanayake
Consultant Haematologist
DGH Chilaw
2. How does bleeding start and stop?
•Blood vessel injury
•The capillary contracts to help slow the bleeding (Vascular phase )
•Platelets make a plug to patch the hole (Platelet phase)
•Clotting factors in plasma work together to form a clot over the plug (Coagulation phase)
•Anticlotting mechanisms are activated to allow remodling of the clot and repair of the damaged vessel (Fibrinolytic phase)
3. Important to remember
•Primary/ congenital bleeding disorders are rare.
•Bleeding due to secondary causes are much common. - Local problems(e.g. polyps, varices, fibroids) - Drugs (e.g.antiplatelets, anticoagulants, antibiotics) - Systemic illnesses(e.g. liver/renal disease, malignancy) - Failed surgical technique - Massive transfusion - Coagulation activation through tissue trauma and or shock, leading to DIC - Procedure-related effects (cardiopulmonary bypass and orthotopic liver transplantation)
•All of the available tests of haemostasis have limitations.
4. Therefore
•Key to the accurate diagnosis of unexpected bleeding lies on clinical assessment, often requiring a visit to the bedside, rather than reliance on investigations.
5. Evaluation of a bleeding patient
• Clinically well patient – Out patient
• Ill patient – Hospitalized
•Obtaining a meaningful history – most important, but more difficult than it sounds!!!
↓
•Physical examination
↓
•Appropriate laboratory tests
(Haemostatic screening tests)
6. Haemostatic history questionnaire
Data collection
Out patients
Hospitalized patients
Patient
Patient
Parents /Guardians
By stander
Family members
Family
Nurses
Medical records
Previous / current lab records
7. Haemostatic history questionnaire
1) Presenting bleeding problem
*Type of bleeding – Spontaneous / Post traumatic - * Site of bleeding
- Skin – Purpura/ Petechiae / Ecchymoses
Petechiae Ecchymoses
8. ► ? Located where trauma is unlikely or unexplained by the severity of injury, e.g. Large bruises after minimal trauma & on the trunk ► Bruises are rare in children < 1 yr ► In active youngsters ecchymotic patches below knee are common ► Simple easy bruising is common in elderly & on long term steroids
9. - Mucosal – Epistaxis - ? Chronic or habitual ( Bleeding when coming from cold → warm environment ) - Can be normal in children - Repeated nose bleeds lasting more than 10 minutes despite compression suggest a local cause or an underlying bleeding disorder. - Involves both sides - Needs ENT referral to exclude any local cause
– Gum bleeding – Important if there is no gingival disease and if it is unrelated to the trauma of brushing.
– Menorrhagia – Difficult to assess - Passage of clots – Retroverted uterus can cause passage of clots due to retention and coming out with change in position (Needs gynae opinion to exclude local causes) - Since menarche / Persistent & sufficient to cause anaemia requiring iron therapy/ transfusions raise the suspicion of a bleeding problem
10. -Deep tissue bleeding – Muscle – Psoas bleeds can mimic appendicitis – Joints - Unexplained ‘arthritis’ or joint swelling - Spontaneous h’ge into synovial joints is highly suspicious of a coagulation disorder esp. in males (? Haemophilia A/B) – Life threatening bleeds – - Intracranial - ? Rupture of aneurysm / Vascular malformation - Retroperitoneal bleeding – may mimic renal colic
- H’ge in to bowel wall – may mimic intestinal obstruction
– Haematetmisis/malaena/haematuria/haemoptytsis - Without any explainable cause
11. 2) Past history of bleeding - Prolonged bleeding after trauma or surgery - ?profuse or intermittent - Extent of bleeding in relation to the degree of trauma - ? Delayed bleeding / poor wound healing – Could be a coagulation disorder - Umbilical stump bleeding – Coagulation factor def. (F XIII def.) - List all the operations & sig. trauma – To assess whether Pt had met with reasonable haemostatic challenges and the ability to withstand them
- Episodes of bleeding - Blood products/ drugs administered / ways & means used to control bleeding & the response
12. • Tonsillectomy & adenoidectomy – If had no peri-op excessive bleeding → unlikely to be a bleeder (as it is a very vascular area)
• Circumcision – may be the 1st bleeding manifestation in a muslim child
• NVD & post partum period
• Tooth extractions - Profuse in upper molar - Brisk bleeding for 1 hour - Serous oozing for 2 days
NL occurrence for any person, not considered as a bleeder
13. 3) Family history
- Blood relatives with bleeding problems - Immediate & extended family ( Draw a family tree) - Affected members-?Male/female/both (X-linked/ autosomal) - Type of bleeding - ? Similar or not - Diagnosis - ? Known ( Go through the diagnosis cards or previous records and see whether the diagnosis is properly established by investigations) - Hx of bleeding problems in relation to surgery or trauma
14. 4) General health - Evidence of a disorder known to be associated with a bleeding tendency
- Chronic liver disease - Renal disease - MPD ( ↑ but abnormal Plt ) - Malignancy with liver deposits - Malabsorption - SLE - Leukaemia ( Can be associated with DIC ) - Congenital Ht disease ( Can be associated with vWD) - Myeloma ( Can be associated with acquired vWD )
15. 5) Drug history - Antiplatelet drugs – Aspirin/ NSAID / Garlic - Anticoagulant therapy – Warfarin / heparin - Prolonged antibiotic therapy (Affects vit K absorption) - Change in medication
6) Evidence of abuse
(Suspect when ecchymotic patches in children)
- Ecchymoses of various colours ( Child had been abused
for a long period)
7) Self- inflicted injury - Patches in accessible areas - Mostly linear & parallel to each other
17. •In a hospitalized patient ;
- Whether bleeding seems appropriate for the injury / surgery
- Single / multiple sites involved
- Wounds / IV sites esp. old IV sites / previous finger or heel prick sites / bleeding time site
- Petichiae in dependent location
- Bruising over the flank ( suggest retroperitoneal h’age)
- Fluid collection bags (urine, gastric, wound drainage, pleural fluid)
18. Petechiae
Spider naevi
Telangiectasias
Haemophilic arthropathy Anaphylactoid purpura In HSP Skin plaques in amyloidosis
19. Findings
Coagulation disorders
Plt / Vascular dosorders
1. Petechiae
Rare
Characteristic
2.Deep dissecting haematoma
Characteristic
Rare
3.Superficial ecchymoses
Large & solitary
Characteristic , small & multiple
4.Haemarthrosis
Characteristic
Rare
5.Delayed bleeding
Common
Rare
6.Bleeding from cuts
Minimal
Common
7.Sex
Common in males (80-90%)
Common in females
8.Positive F/H
Common
Rare except vWD
20. With the information obtained by Hx , Ex & previous lab records
Identify 4 categories of patients a. Definite bleeder b. Questionable, need more tests to decide c. Questionable as haemostatically not fully challenged d. Not a bleeder
• All pts except category ‘d’ should be subjected to the first line screening tests.
21. First line screening tests
•Full blood count
•Blood picture (EDTA / non- EDTA)
•Skin bleeding time
•Activated Partial Thromboplasin Time (APTT)
•Prothrombin time (PT)
•Thrombin Clotting Time (TCT)
•Fibrinogen ●Interpret the tests in relation to the age & physiological changes of the pt’s body
23. Skin bleeding time (BT)
•Screening test for primary haemostasis (Plt – vessel interaction & haemostatic plug formation) in ambulatory children & adults with an undiagnosed bleeding condition.
•BT is also altered by hematocrit, skin quality and the technique.
•The inter and intraobserver variation amongst the technicians is as high as 20%.
24. BT cont…
•Does not necessarily reflect bleeding from any other site1.
•Limited usefulness in invasive procedures2
- In the absence of a Hx of a bleeding disorder, BT is not a useful predictor of the risk of haemorrhage associated with invasive procedures.
- A normal BT doesn’t exclude the possibility of excessive haemorrage associated with invasive procedure.
- Cannot reliably identify pts who may have recently ingested aspirin/ NSAID or those who have plt defects attributable to these drugs. 1Guideline on the assessment of bleeding risk prior to surgery or invasive procedures ,BCSH, 2007 2Screening tests of haemostasis –Disorders of haemostasis & thrombosis by Hathaway WE, Goodnight SH– 2nd edition
25. •APTT
- Sensitive to coagulation abnormalities of the ‘intrinsic’ pathway (Factors XII, XI, IX , VIII, V & X)
- Less sensitive to deficiencies of prothrombin (II)
& fibrinogen
•PT
-Sensitive to coagulation abnormalities of the ‘extrinsic’pathway (Factors VII, X, V & II)
-Usually not prolonged by low fibrinogen unless the
level is <100mg/dl
•TCT
- Measures the amount and quality of fibrinogen
& the rate of conversion of fibrinogen to fibrin
26. •Fibrinogen - 2 assay methods – Quantitative / Qualitative - Normal adult levels ranges from 175 – 400mg/dl - Minimal level for normal haemostasis is approximately
75-100mg/dl - Commonly used screening tests (PT, APTT, TCT) usually are not prolonged until the fibrinogen level falls <100mg/dl
27. Capillary tube clotting time (CT)
•Very much out dated test.
•Used in past (when PT/APTT were not available) to assess both the intrinsic and extrinsic pathways of coagulation.
•Getting deranged only when there is a drop in coagulation factor of more than 40% of normal values. (Not sensitive)
•Not carried out at 37°C (NL human temperature)
•No clear cut end point. The test is commonly
misinterpreted because only the initial traces of
thrombin formed is enough to cause the clotting in the outermost part of column of blood within the capillary tube.
•Loss of considerable amount of man-hours per day to the hospital laboratory carrying out the (BT) & CT
29. Abnormal screening tests in various bleeding disorders
Disorder
↓ Plt
↑ BT
↑ APTT
↑ PT
↑ TCT
↓ Fib
1.Thrombocytopaenia
X
2.Plt dysfunction
X
3.Haemophilia
X
4.Early Liver dis./
FVII def.
X
5.Dysfibrinogenaemia (mild)
X
6.Hypofibrinogenaemia (mild)
X
7.Advanced liver dis.
X
X
X
X
X
X
8.Advanced renal dis.
X
X
X
X
X
X
9.DIC
X
X
X
X
X
X
30. •If all the first line screening tests are normal ↓ No further investigations are necessary
Except in
•Positive family history
•Definite/ significant bleeding history with
normal first line tests
31. •Definite bleeding history with negative haemostatic screening results can occur
- Mild haemophilia - Mild vWD - F XIII deficiency - Vascular defects - α2 antiplasmin deficiency - Plasminogen activator inhibitor – 1 deficiency
32. 2nd line coagulation tests
•Selection criteria 1. Abnormal 1st line screening test 2. Significant bleeding Hx with normal 1st line tests 3. Positive F/H with normal 1st line tests
•Type of the 2nd line test/s are decided by; 1. Abnormality detected in 1st line test/s 2. Nature of bleeding in patient /family
33. 2nd line screening tests
1.Low platelets - Liver function tests - Bone marrow – if clinically indicated
2. Near NL plt count /abnormal plt morphology - Platelet function tests
3. ↑ BT - Platelet function tests - von willbrand antigen level - Ricof activity - Multimer analysis
34. 4. Prolonged APTT - Mixing and correction studies - Factor assay - Inhibitor screening - Exclude heparin effect
5. Prolonged PT - Mixing and correction studies - Factor assay - Liver function tests
6. Prolonged TT - Mixing tests - Toludine blue test
35. 7. ↑ BT, APTT, PT, TT with low platelets - D-Dimer - FDP
8. ↑ BT, APTT, PT, TT with normal platelets - Clauss test (Dysfibrinogenaemia)
9. Normal BT, APTT, PT, TT, platelets, fibrinogen - Factor XIII assay / clot solubility test
36. Pre operative haemostatic evaluation
•Routine /indiscriminate pre-operative performance of bleeding screening tests (BT /APTT/ PT) has not demonstrated to be significantly predictive of haemorrhagic complications or cost effective.
•A screening coagulation profile is not a substitute for the history and physical examination.
37. •Basic screening lab tests (FBC/ PT/APTT) are reserved/ selected depending on: a) Nature of the patient 1. With positive assessment
2. Who are at higher risk of bleeding because of
special circumstances e.g - Children (<13 yrs) even without any bleeding Hx (Not met with a major haemostatic challenge) - Liver disease b) Nature and site of Sx e.g Major Sx at a very vascular/critical site
c) Mode of anaethesia e.g- For GA – Plt >50,000/μl For spinal/ epidural – Plt > 80,000/μl
38. Refrain from transfusion of blood products unnecessarily to normalize clotting profiles in pts with no bleeding and no plans for invasive procedures!!!
e.g 1. Haemophilia patients -↑↑APTT
2. Chronic liver cell disease Pts -↑↑PT, ↓Plt
3. Burn patients - ↑PT, ↑APTT, ↓Plt
4. DIC - ↑PT, ↑APTT, ↓Plt
5. High INR
39. Take home message
•Obtain a meaningful history
↓
•Physical examination
↓
•Appropriate laboratory tests
(Haemostatic screening tests)