Bleeding tendency

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hematology

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Bleeding tendency

  1. 1. APPROACH TO BLEEDING TENDENCY Hamad Emad H. Dhuhayr
  2. 2. CONTENT • Overview • approach to bleeding tendency 1. Taking history 2. Physical examination 3. Laboratory • references
  3. 3. VASCULAR CONTRACTION 1. Local myogenic spasm 2. Local autacoid factors from traumatized tissue and blood platelets 3. Nervous reflexes
  4. 4. Red blood cell Platelet
  5. 5. Red blood cell Platelet
  6. 6. Red blood cell Platelet Von Willebrand factor
  7. 7. Red blood cell Platelet Von Willebrand factor
  8. 8. Red blood cell Platelet Von Willebrand factor
  9. 9. Red blood cell Platelet Von Willebrand factor
  10. 10. Red blood cell Platelet Von Willebrand factor
  11. 11. Red blood cell Platelet Von Willebrand factor
  12. 12. Red blood cell Platelet Von Willebrand factor
  13. 13. Red blood cell Platelet Von Willebrand factor
  14. 14. Red blood cell Platelet Von Willebrand factor
  15. 15. Red blood cell Platelet Von Willebrand factor Fibrin polymer
  16. 16. Red blood cell Platelet Von Willebrand factor Fibrin polymer
  17. 17. Red blood cell Platelet Von Willebrand factor Fibrin polymer
  18. 18. EVALUATION OF THE PATIENT •HISTORY •PHYSICAL EXAMINATION •LABORATORY EVALUATION
  19. 19. 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
  20. 20. Primary Hemostatic defect Secondary Hemostatic defect
  21. 21. PHYSICAL EXAMINATION • Current hemorrhage • Nature and extent • Intercurrent illnesses • Liver disease • Petechiae/ecchymoses
  22. 22. LABORATORY ASSESSMENT • GUIDED BY HISTORY • SCREENING TESTS • PT • APTT • PLATELET COUNT • FIBRINOGEN • THROMBIN TIME
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. BLEEDING TIME
  27. 27. 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
  28. 28. PLATELET AGGREGATION STUDY
  29. 29. 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
  30. 30. PROTHROMBIN TIME (PT) PT : test extrinsic and common pathway
  31. 31. ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) aPTT : test intrinsic and common pathway
  32. 32. 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%
  33. 33. INTERPRETATION OF ABNORMAL COAGULOGRAM ISOLATED PROLONGED PT ISOLATED PROLONAGED APTT PROLONGED PT AND APTT
  34. 34. 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
  35. 35. 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
  36. 36. Acquired FVIII inhibitor
  37. 37. 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
  38. 38. SUMMARY • HISTORY & PHYSICAL EXAMINATION • LABORATORY TESTS • SCREENING TESTS • SPECIFIC DIAGNOSTIC TESTS • DIAGNOSIS-SPECIFIC THERAPY • FACTOR REPLACEMENT • DRUGS
  39. 39. REFFERENCES • KUMAR • CECIL • WEBSITE

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