33. bleeding disorders ( coagulopathies, thrombocytopenia, thrombocytopathy)

Question 1

what to mention

Answer 1

list disorders of hemostasis 
ddx of hemostatic problems 
DIC 
coagulopathies 
rodeticide poisoning 
immune mediated thrombocytopenia 
von willebrand - thrombocytopathy

Question 2

what are the disorders of hemostasis

Answer 2

coagulopathy - decreased clotting factor
thrombocytopenia: low platelet count
thrombocytopathy: decreased platelet function
vascular disorders: rare
DIC: coagulo + thrombocytopenia

Question 3

ddx of hemostatic problems - list

Answer 3

history: rodenticide? first time?
coagulopathy def
thrombocytopathy/penia + vascular disorder def
diagnostic test: in exam room, laboratory test

Question 4

what is coagulopathy

Answer 4

deep bleeding: hematoma, hemothorax, hemoperitoneum
clotting time increase
APTT, PTT increase
ACT increase

Question 5

what is Thrombocytopenia, thrombocytopathy and vascular disorder

Answer 5

superficial bleeding: petechia, ecchymosis, epistaxis, melena, hematuria
bleeding time increase
clot retraction time increase or same
platelet count decrease or same

Question 6

diagnostic tests in examination room

Answer 6

clotting time: 10-20 min in glass tube 
ACT: <120 sec 
bleeding time: <5 minutes 
clot retraction <2 hours 
blood smear: 10-15 PLT in oil immersion, PLT and RBC morphology

Question 7

diagnostic test in lab

Answer 7

test tube with Na- citrate and EDTA
APTT: intrinsic and common pathway
PTT: extrinsic and common pathway factor VII
FDP or D-dimer, fibrinogen: DIC diagnosis
PLT count 200-800 g/l

Question 8

rodenticide poisoning pathophysiology

Answer 8

dicoumarol poison

competetiv antagonist of factors: II, VII, IX, X

Question 9

clinical signs of rodenticide poisoning

Answer 9

acute collapse, shock - bleed into chest
anemia
dyspnoe
hemothorax

Question 10

diagnosis of rodenticide poisoning

Answer 10

history, access to poison
PTT
APPT, ACT, clotting time

Question 11

treatment of rodenticide poisoning

Answer 11

treat shock: fluid, plasma expanders
fresh whole blood, fresh frozen plasma
vitamin K
(vomit induction if less than 2 hours since ingestion)

Question 12

immune mediated thrombocytopenia pathogenesis and diagnosis

Answer 12

idiopathic immune mediated destruction of platelets

diagnosis by exclusion of other factors, specific tests not reliable

Question 13

clinical signs of IM thrombocytopenia

Answer 13

siperficial bleeding
splenomegaly
platelet count decreased (below 25 g/l)

Question 14

what should we rule out in case of immune mediated thrombocytopenia

Answer 14

drug induced thrombocytopenia: PBZ, estrogen, b-lactam
dog: tick born - babesia
cat: FeLV, FIV
DIC

Question 15

treatment of immune mediated thrombocytopenia

Answer 15

stop bleeding
fresh whole blood, platelet rich plasma
immunosuppression: prednisolone

Question 16

von willebrands disease - thrombocytopathy pathogenesis

Answer 16

common inherited of Doberman pincher, GSD
absence, low conc or abnormal function of vWFactor
sometimes together with low conc of factor VII
vWF is an important platelet adhesive protein

Question 17

von willebrand clinical sign and diagnosis

Answer 17

spontaneous bleeding is rare, prolonged surgical bleeding 
increased bleeding time 
clot retraction time increases 
platelets are same 
ACT, APTT same or increased
measurement of vWF by electrophoresis

Question 18

von willebrand disease treatment

Answer 18

desmopressin (synthetic ADH) causes release of vWF from endothelial cells. (before surgery or during bleeding)
fresh whole blood, fresh frozen plasma

Question 19

DIC what is it

Answer 19

disseminated intravascular coagulopathy

a consumptive coagulopathy

Question 20

DIC pathogenesis

Answer 20

excessive systemic intravascular coagulation -> multi organ micro thrombosis
paradoxical bleeding caused by inactivation and consumption of platelets and coagulation factors

Question 21

DIC triggers

Answer 21

endothelia damage 
platelet activation 
release of tissue coagulants 
these can be triggered by many things 
hemolysis, hypoxia, shock, infectious disease, pancreatitis

Question 22

clinical signs of DIC

Answer 22

ofetn subclinical
microthrombi: signs of organ failure in kidney, liver and lung
superficial or deep bleeding

Question 23

DIC diagnosis

Answer 23

FDP or D-dimer, fibrinogen decrease
increased ACT, APTT, PTT
thrombocytopenia, scistocytosis

Question 24

treatment of DIC

Answer 24

treat primary cause
fresh blood, fresh frozen plasma
heparin
plasma expanders, crystalloids