Approach to bleeding

Question 1

Bleeding in skin, mucous membranes (eg. epistaxis, gum, vaginal, GIT) is more indicative of which part of hemostasis?

Answer 1

Primary (platelet disorders)

Question 2

Bleeding in deep soft tissue/Hemarthrosis (joints, muscle) is more indicative of which part of hemostasis?

Answer 2

Secondary (coagulation factor disorders)

Question 3

Petechiae is seen in (platelet disorders/coagulation factor disorders)

Answer 3

Platelet disorders

Question 4

What is the difference in bruises (ecchymosis) seen in platelet vs coagulation factor disorders?

Answer 4

Platelet: small, superficial bruising

Coagulation factor: large, deep bruising

Question 5

Bleeding after cuts/scratches is seen in (platelet disorders/coagulation factor disorders)

Answer 5

Platelet disorders

Question 6

What is the difference in post-trauma/surgery bleeding seen in platelet vs coagulation factor disorders?

Answer 6

Platelet: immediate, mild

Coagulation factor: delayed (1-2 days) , severe

Question 7

What are important considerations for a bleeding Hx?

Answer 7

1) Severity:
- qty, freq
- anemia
- local/systemic (site)

2) Congenital vs acquired
- onset, recurrence
- FH
- DH (antithrombotics, OTC, TCM)
- SH (diet, alcohol)
- PMH (bleeding problems, comorbidities)

3) Platelet vs coagulation
- bleeding pattern (mucocutaneous vs muscles/joints)

Question 8

What are important components in a bleeding PE?

Answer 8

1) Hemodynamics (oedema)
2) Skin (petechiae, bruising, hematoma, hemarthrosis)
3) Cause (joint abnormalities, organomegaly, non-accidental injury)

Question 9

True or false: History &
examination
can rule out
most bleeding
disorders

Answer 9

True

Question 10

When is a lab screening indicated in a px with bleeding disorder(s)?

Answer 10

Abnormal bleeding Hx and/or signs of bleeding in PE

Question 11

What are the 1st line Ix for bleeding screens?

Answer 11

1) FBC (platelet)
2) PBF
3) Coagulation tests
- PT
- aPTT
- Fibrinogen

Question 12

What are the 2nd line Ix for bleeding screens?

Answer 12

1) Mixing test
2) Platelet f(x) test
3) Specific coagulation factor levels (F8, F9, vWF)
4) Specialised tests (lupus anti-coagulant, factor inhibitors)

Question 13

What does a mixing test tell you?

Answer 13

If px has coagulation factor deficiency

No correction: Inhibitor or lupus anticoagulant

Correction: Factor deficiency

Question 14

True or false: Mild bleeding does not mean bleeding disorder

Answer 14

True

Mild bleeding symptoms reported
in healthy persons
* epistaxis (in 5% to 23%)
* gum bleeding (in 7% to 47%)
* menorrhagia (in 23% to 68%)

Question 15

True or false: Normal tests
can rule out a bleeding
disorder

Answer 15

False

Test does not mirror what happens
in body: no vessel wall and
endothelium
* Platelet count: number only
* PT/APTT: fibrin detection only
* Rare bleeding disorders with
normal PT and APTT e.g. FXIII
deficiency

Question 16

What are possible etiologies in a px with ↑aPTT only?

Answer 16

1) Hemophilia (congenital/acquired)
2) Heparin
3) Lupus anticoagulant

(Intrinsic: F7, 9, 11, 12)

Question 17

What are possible etiologies in a px with ↑PT only?

Answer 17

F7 deficiency

(Extrinsic)

Question 18

What are possible etiologies in a px with ↑PT and ↑aPTT?

Answer 18

1) Warfarin*, Rivaroxaban, Apixaban, Dabigatran)
2) DIC
3) Liver disease

(Common: Fibrinogen, prothrombin, FV, F10)

Question 19

What are possible etiologies in a px with ↑fibrinogen?

Answer 19

Acute phase reactant of inflammation

Question 20

What are possible etiologies in a px with ↓fibrinogen?

Answer 20

1) DIC
2) Hypofibrinogenemia
3) Dysfibrinogenemia
4) Liver disease

Question 21

What are the different treatments for each type of vWF disease?

Answer 21

1) Type 1 (deficiency)
- Desmopressin
- Cryoprecipitate

2) Type 2 (dysfunction)
3) Type 3 (absent)
- both: F8/cyroprecipitate