303. Bleeding Flashcards
After bleeding what are the three processes the body undertakes to stop bleeding?
Vasocontriction
Gap plugging
Coagulation cascade
What common vascular deficincies lead to increased bleeding?
Hereditary talangectasia
Eshler dahmos
Infection (meningitis)
steroids, scurvy
HSP
What are the platelet dysfunctions that cause increased bleeding?
aplastic anaemia, megaloblastic anaemia, marrow suppresion (chemo)
SLE, ITP, heparin
DIC, TTP, HUS
NSAIDS
What common disorders cause problems with the coagulation cascade?
Heamophilia, Von willibrands disease,
Anticoagulants, liver disease, DIC, Vitamin K deficiency
What is haemophilia A?
X linked recessive Factor 8 deficiency
up to 30% dont have family history
How does it present?
How is heamophilia A diagnosed
Depends on severity
Heamoartorisis- bad joint problems
Muscle heamotomas- compartment syndrome
Diagnosis is made by prolonged APTT and reduced factor 8 assay
How do you manage heamophilia A?
Get help
Avoid NSAIDS and IM injections
Desmopressin raises factor 8 levels
major bleeds- recombient factor 8 levels
What is heamophilia B?
Factor IX deficiency, x linked
What is acquired heamophilia?
Causes big mucousal bleeds
Factor 8 deficiency
What pathologies lead to reduced vitamin K absorbtion
Fat malabsorption syndromes
diffuse liver disease
Absence of vitamin K synthesizing flora (antibiotics, babies)
What is immune thrombocytopeania?
Antiplatelet autoantibodies, typically develops after infection in the young causes self limiting purpura
Chronic IPT typically causes bleeding, purpura, epistaxis and menorrhagia
How is ITP treated?
Iv prednisolone
Immunoglobulin to increase platelets
splenomegaly
rituximab
What is von willibrands disease?
deficiency in VwF that binds platelets with factor 8
How is von willibrands diseases managed?
Managed by expert, avoid NSAIDS
Desmopressin for mild bleeds,
VwF containing factor 8 for surgery or major bleeds
What are the causes of bleeding with a prolonged prothrombin time
Extrinsic system pathologies:
Liver disease
DIC
Vit K deficiency
Warfarin
What prolongs activated partial prothrombin time?
Extrinsic system pathologies:
Heparin
Heamophilia
DIC
Liver disease
How do you manage someone with a bleeding disorder?
If shcoked, resuccitate
If bleeding continues discuss need for FFP, cryoprecipitate, platelets. Speak to heam
What are the typical bleeding results for heparin?
Increased INR,
increased APTT,
increased thrombin time,
normal platelets
With regards to DIC discuss the heamatological values?
PT- increased
APTT- increased
Thrombin time- increased
Platelet count decreased
Liver disease. what are the heamatological values?
Increased INR,
increased APTT,
increased/normal thrombin,
normal/low platelets
Vit k defiecency heamatological values
Increased INR, Increased APT
normal thrombin, normal platelets
Heamophili and VwD what are the heamatological values
Normal INR
Increased APTT
Normal platelets
Normal Thrombin
When would you correct red cells
anaemia or blood loss
When would you transfuse or platelets?
If actively bleeding or count is below 20
If getting surgery get advice if platelets are below 100
Fresh frozen plasma is transfused in which scenario?
DIC
Warfarin overdose
Liver disease
TTP
What are the early complications of acute reactions
acute heamolytic reaction
anaphylaxis
bacterial contamination
febrile reactions
allergic reactions
acute lung injury
What is an aitologous transfusion?
Patients own blood taken and save it for later. Usually use EPO.
What is an autologous transfusion?
Patients own blood taken and save it for later. Usually use EPO.
When would you transfuse or platelets?
If actively bleeding or count is below 20
If getting surgery get advice if platelets are below 100
Fresh frozen plasma is transfused in which scenario?
DIC
Warfarin overdose
Liver disease
TTP
What are the early complications of acute reactions
acute heamolytic reaction
anaphylaxis
bacterial contamination
febrile reactions
allergic reactions
acute lung injury
What is an aitologous transfusion?
Patients own blood taken and save it for later. Usually use EPO.
What are symptoms of an acute haemolytic reaction?
Agitation
Increased temperature
Rapid onset
REduced BP
Flushing
Abdo/chest pain
DIC
How should an acute haemolytic reaction be managed?
Stop transfusion
Phone heamatology
send FBC, U&E, clotting, cultures and urine
Keep line open with saline
Treat DIC
What are the symptoms of an analyphylactic reaction to a transfusion?
Bronchospams
Cyanosis
Reduced BP
Soft tissue swelling
What are the symptoms of a bacterial reaction to transfusion?
Increased temperature
Reduced BP
Rigor
Managed same as acute heamolytic reaction except broad spectrum antibiotics are given
How do you differentiate with a transfusion associated lung injury and fluid overload?
Both give dyspnoea, hypoxia, and CXR changes
TRALI- White out on CXR, hypotension
FLuid overload- Hyperte3nsion, raised JVP
How do you manage TRALI?
Stop transfusion
Give 100% O2
Treat as ARDS- ITU, CPAP, Low pressure ventilation with with high peak expiratory pressures. Art. line, conservative fluid management
How do you manage Non heamolytic febrile transfusion reactions and allergic reactions (not anaphylaxis)
Non haemolytic reaction- fever 30-60 mins after onset. Slow or stop transfusion and give paracetamol
Allergic reation- urticaria and itch, stop or slow transfusion and give IV chlorophenamine
