Anemia and Bleeding Flashcards
What History or questions with anemia
- Duration of symptoms?- Chronic vs acute
- Episodic?- Drug or illness driven?
- Associated symptoms?
- Jaundice/dark urine= hyperbili=hemolysis
- Medications
- Iron source in diet?
- Family Hx- early gallstones, food intolerance, etc.
Review of symptoms in anemia
- Feeding?
- Bruising/bleeding
- Rashes
- Joint/Bone pain
- Fevers
- Other symptoms: viral syndromes in past couple weeks
PE in anemia pt
- CV: Tachycardia, murmur, CHF (feeding problems)
- Lungs: Crackles, wheezes
- Liver/spleen enlargement
- Ascites/edema
- Pallor (palmar creases-lighter color)
Lab eval in anemia
- Basic workup: CBC, Peripheral smear, retic count. Bilirubin, DAT (Coombs Test), UA
- Focused workup: Depends on Hx/PE. Includes iron studies, osmotic fragility, Hgb electrophoresis, G-6PD
- Retic: gauge RBC production rate
- RDW: Gauge homogeneity of RBC population.
Cell size normocytic, retic increased. Likely Dx?
1) Blood loss
2) Hemolysis
3) AIHA
Cell size normocytic, decreased retic. Likely Dx
-Anemia of chronic disease
Cell size macro, increased retic. Likely DX?
- Blood loss
- Hemolysis
Cell size Macro, retic decreased. Likely Dx?
- Folate/B12 def.
- Drug induced
- Marrow failure
- AIHA
Cell size micro, retic decrease. Likely Dx?
- Iron def.
- AIHA
Cell size micro, retic increased. Likely dx?
- Thalassemia
- AIHA
Iron deficiency anemia would look like what under microscope?
-Microcytic, hypochromic aregenerative anemia.
Leading cause of anemia in Children? And leading cause of MR and LD in children?
Iron deficiency
Pathophys of Iron deficiency? (3)
1) Inadequate dietary intake
2) Excessive consumption (growth spurt)
3) Excessive loss (GI blood loss, menses, pulm bleeding, excessive sports in children/teens)
Treatment of Iron deficiency
- Find site of blood loss.
- Iron replacement- Ferrous sulfate 3-6 mg Elemental Iron/Kg/day TID- Retic increase in 3-5 days, Hgb increases 0.25 grams/dl per week, treat 4-6 months. Replace BM stores and stores elsewhere.
- Patients with Chron’s or other problems that dont respond to Ferrous sulfate can be given IV iron
What is this: Clinical syndrome where there is just about enough iron to make a normal Hgb, but no reserve. Common in teen girls (diet restriction, menstrual loss, exercise). What can this cause in pregnancy?
Non Anemia (latent) iron deficiency -Iron deficient babies- neurologic problems, lasting behavioral and intellectual defects.
The most common form of anemia in adults. Second most common in childhood. Seen with common infection. Stimulation of inflammatory processes.
Anemia of Chronic Dosorders
What does Anemia of Chronic disorders look like under mcroscope
Normocytic/Normochromic anemia
Anemia of Chronic disorders lab features
- Transferrin low
- Serum iron low
- Serum transferrin receptor low
- TIBC low
Bleeding disorders come from three sources. Match number with letter:
1) Vascular phase
2) Platelet Phase
3) Humoral phase
A) Thrombocytopenia, VWD
B) Ehlers-Danlos Syndrome
C) Hemophilia, DIC
1-B
2-A
3-C
Each phase has a pattern of bleeding:
1) Humoral:
2) Vasc/Platelet
1) Bleeding into soft-tissue/joints
2) Muco-cutaneous bleeding
Bruises age and change color. How old is a…
1) Red (swollen tender)
2) Blue
3) Green
4) Yellow
5) Brown
6) Clear
1) 0-2 days
2) 2-5 days
3) 5-7 days
4) 7-10 days
5) 10-14 days
6) 2-4 weeks
Nosebleed Lab Eval
Evaluate the phases of coagulation:
- Platelet phase:
1) CBC with platelet count
2) Platelet fxn tests
3) bleeding time (also vascular phase) - Humoral Phase:
1) prothrombin time
2) Partial thromboplastin time
PTT normally 34-36 sec. What about a kid with PTT of 38. WHat is DDX? and what is work-up
DDX:
- Lab error
- Vit K def (Antibiotic, diet)
- Mild hemophilia or VWD
- Normal variation
- Inhibitor
Work-up:
-If recent diet or AB concerns, give vit K for 2 weeks and repeat. If still abnormal, do a mixing study.
After a mixing study if you have a:
1) Corrected PTT
2) Uncorrected PTT
What do yo look for
1) Factor levels: VWF
2) Inhibitor search: Lupus anticoagulant panel, anticardiolipin IgG and IgM, anti B2 microglobulin
1) Classical or Hemophilia A is deficiency of factor ____.
2) Hemophilia B, or christmas disease is deficiency of Factor ____.
1) VIII
2) IX
How to treat hemophilia
-Give factor
~FACTOR VIII: 50 units/kg IV as bolus then 4 units/kg/hr IV continuous infusion startings ASAP after bolus
~FACTOR IX: 100 units/kg IV as bolus then 5 units/kg/hr IV continuous infusion
* In emergencies, give factor BEFORE you image patient.
Deficiency of normal VWF fxn due to either deficiency or mutation of the protein. WHat are common subtypes?
Type 1: deficiency
Type 2: mutation
type 3: No detectable factor
T/F: VWF is estrogen dependent
True- important to get menstrual hx. Also bleeding after child birth
Von Willebrand Disease prolongs PTT due to deficiency of VIII which is stabilized by VWF. Treatment with:
1) Agent to increase VWF
2) Factor concentrates
3) Antifibrinolytics
1) DDAVP (Stimate)
2) Humate P and Alphanate SD
3) Amicar
What is Immune Thrombocytopenic Purpura
Immune attack on platelets.
- Opsonization rather than lysis
- -In pre-pubertal kids, usually post viral infection by a couple of weeks.
- If platelets drop low enough, small bleeding sites (petechiae) form
- Acute <1 yr
Treatment of Immune Thrombocytopenic Purpura
1) Observation
2) IVIG
3) Prednisone
Second line: WInRho SD, Rituxan, Splenectomy
