2. Bleeding Flashcards
History taking bleeding
Examination bleeding
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Broad categories of why someone may have prolonged bleeding/symptoms of bleeding?
Clotting cascade deficiencies
- congenital eg haemophilia
- acquired eg lymphoma, SLE, amyloidosis
Platelet dysfunction
- VWF disease
- thrombocytopenia (destruction) eg ITP, TTP, HIT, HUS, medications, alcohol
- thrombocytopenia (decreased production) eg leukemia, myelodysplastic, myeloma
Widespread coagulopathy
- DIC
- low vitamin K (newborn, warfarin)
- major haemorrhage
- liver failure
Other
- vasculidities
- scurvy
symptoms that indicate a platelet disorder
Bleeding immediately after trauma
Bleeding of mucus membranes- epistaxis, bleeding gums
Cutaneous and subcutaneous bleeding- petechiae, purpura, easy bruising
Menorrhagia
symptoms that indicate a coagulation disorder
Delayed bleeding after trauma
Deep tissue bleeding- hemarthrosis , hematomas
Large, palpable ecchymoses
Presentation haemophilia
- bleed excessively in response to minor trauma
- spontaenous haemorrhage eg bleeding into joints (haemoathrosis) and muscles are a classic feature of severe haemophilia
intracranial haemorrhage, haematomas and cord bleeding in neonates.
Abnormal bleeding can occur in other areas:
Gums
Gastrointestinal tract
Urinary tract causing haematuria
Retroperitoneal space
Intracranial
Following procedures
investigations haemophilia
Diagnosis is based on bleeding scores, coagulation factor assays and genetic testing.
Prolonged APTT
Low factor VIII/IX coagulant level with normal levels of vWF
Others are normal
Family history
management haemophilia
The affected clotting factors (VIII or IX) can be replaced by intravenous infusions. This can be either prophylactically or in response to bleeding.
management of acute bleeding/ preventing bleeding during surgical procedures haemophilia
Infusions of the affected factor (VIII or IX)
Desmopressin to stimulate the release of von Willebrand Factor
Antifibrinolytics such as tranexamic acid
haemophilia A vs B are which clotting factor deficiencies
Haemophilia A is caused by a deficiency in factor VIII (8).
Haemophilia B (also known as Christmas disease) is caused by a deficiency in factor IX. (9)
which is the most common hemophilia
A
inheritance hemophilia
X linked recessive
risk with what is a complication of hemophilia treatment?
IV clotting factors (VIII or IX)
A complication of this treatment is formation of antibodies against the clotting factor resulting in the treatment becoming ineffective.
acquired coagulation disorders? what can cuase? pathophysiology?
Lymphoma and SLE can lead to acquired clotting factor deficiencies by the creation of antibodies against clotting factors
presentation von willebrand disease
Often asymptomatic
Bleeding from mucosa (epistaxis, menorrhagia, gums)
Easy bruising
Postoperatively
Family history of bleeding
invetsiations von willebrand
Prolonged bleeding time with normal platelet count
APTT may be prolonged or normal
Decreased plasma vWF
Decreased factor VIII activity
management VWF disease
Care when using NSAIDs, antiplatelets (e.g. aspirin, clopidogrel): can cause increased bleeding
Desmopressin-induces vWF release from endothelial cells
Factor VIII concentrates containing vWF-during surgery
what should you not / be cautious when prescribing vwf
NSAIDs, antiplatelets (e.g. aspirin, clopidogrel): can cause increased bleeding
what symptoms are associated with thrombocytopenia below 50x 1089/L
Nosebleeds
Bleeding gums
Heavy periods
Easy bruising
Haematuria (blood in the urine)
Rectal bleeding
what are platelet counts below 10x1089/L at risk of?
high risk for spontaneous bleeding. Particularly concerning are:
Intracranial haemorrhage
Gastrointestinal bleeding
What blood product have the highest risk of bacterial contamination
Platelet transfusions have the highest risk of bacterial contamination compared to other types of blood products
At what platelet level should you give platelets in active bleeding
Offer platelet transfusions to patients with a platelet count of <30 x 10 9 with clinically significant bleeding (World Health organisation bleeding grade 2- e.g. haematemesis, melaena, prolonged epistaxis)
Platelet thresholds for transfusion are higher (maximum < 100 x 10 9) for patients with severe bleeding (World Health organisation bleeding grades 3&4), or bleeding at critical sites, such as the CNS.
It should be noted that platelet transfusions have the highest risk of bacterial contamination compared to other types of blood product.
At what platelet level should you give patients platelets pre-invasive procedure
Platelet transfusion for thrombocytopenia before surgery/ an invasive procedure.
Aim for plt levels of:
> 50×109/L for most patients
50-75×109/L if high risk of bleeding
>100×109/L if surgery at critical site
At what platelet level should you give patients platelets if no active bleeding and no planned invasive procedure
A threshold of 10 x 109 except where platelet transfusion is contradindicated or there are alternative treatments for their condition
For example, do not perform platelet transfusion for any of the following conditions:
Chronic bone marrow failure
Autoimmune thrombocytopenia
Heparin-induced thrombocytopenia, or
Thrombotic thrombocytopenic purpura.
what is ITP
Immune (or idiopathic) thrombocytopenic purpura (ITP) is an immune-mediated reduction in the platelet count. Antibodies are directed against the glycoprotein IIb/IIIa or Ib-V-IX complex. It is an example of a type II hypersensitivity reaction.
what type of hypersensitivity reaction is ITP
type 2
Presentation ITP
usually children
bruising
petechial or purpuric rash
bleeding is less common and typically presents as epistaxis or gingival bleeding
Investigations ITP
full blood count should demonstrate an isolated thrombocytopenia
blood film
bone marrow examinations is only required if there are atypical features e.g.
lymph node enlargement/splenomegaly, high/low white cells
failure to resolve/respond to treatment
management ITP
usually, no treatment is required
ITP resolves in around 80% of children with 6 months, with or without treatment
advice to avoid activities that may result in trauma (e.g. team sports)
other options may be indicated if the platelet count is very low (e.g. < 10 * 109/L) or there is significant bleeding.
Options include:
- oral/IV corticosteroid
- IV immunoglobulins
- platelet transfusions can be used in an emergency (e.g. active bleeding) but are only a temporary measure as they are soon destroyed by the circulating antibodies
education and advice ITP
Avoid contact sports
Avoid intramuscular injections and procedures such as lumbar punctures
Avoid NSAIDs, aspirin and blood thinning medications
Advice on managing nosebleeds
Seek help after any injury that may cause internal bleeding, for example car accidents or head injuries
complications ITP
Chronic ITP
Anaemia
Intracranial and subarachnoid haemorrhage
Gastrointestinal bleeding
what is TTP
Thrombotic thrombocytopenic purpura (TTP) is a condition where tiny thrombi develop throughout the small vessels, using up platelets. As the problem is in the small vessels, it is described as a microangiopathy. microangiopathic haemolytic anaemia
TTP is caused by a deficiency in ADAMTS13, a metalloprotease that cleaves von Willebrand factor multimers. This leads to the accumulation of ultra-large von Willebrand factor multimers, which promote platelet aggregation and thrombus formation.
This may be inherited or acquired (Autoimmune disease, where antibodies are created against the protein (acquired)
Pentad TTP
Microangiopathic haemolytic anaemia
Fever
Disturbed neurological function (Tissue ischaemia and end-organ damage)
Renal failure (Tissue ischaemia and end-organ damage)
Thrombocytopenia
treatment of choice TTP
Plasma exchange
Treatment is guided by a haematologist and may involve plasma exchange, steroids and rituximab.
what does ADAMTS13 usually do?
This protein normally:
Inactivates von Willebrand factor
Reduces platelet adhesion to vessel walls
Reduces clot formation
what is heparin-induced thrombocytopenia?
Heparin-induced thrombocytopenia (HIT) involves the development of antibodies against platelets in response to heparin (usually unfractionated heparin, but it can occur with low-molecular-weight heparin). Heparin-induced antibodies target a protein on platelets called platelet factor 4 (PF4).
presentation and pathophysiology HIT?
The condition typically presents around 5-10 days after starting treatment with heparin. HIT antibodies bind to platelets and activate the clotting system, causing a hypercoagulable state and thrombosis (e.g., deep vein thrombosis). They also break down platelets and cause thrombocytopenia. Therefore, there is a counterintuitive situation where a patient is on heparin, has a low platelet count, and develops abnormal blood clots.
