Approach to bleeding disorders

Question 1

Describe examples platelet type bleeding

Answer 1

• Mucosal (bruises, petichae)
• Epistaxis (won’t stop)
• Purpura
• Menorrhagia
• GI
• Post surgical bleeding

Question 2

Describe examples of bleeding when there is a disruption of coagulation factors

Answer 2

• Articular (into joints)
• Muscle haematoma (into muscles)
• CNS (into brain)

Question 3

Things to look for in a bleeding disorder

Answer 3

• Bruising
• Epistaxis
• Post surgical bleeding (dental, circumcision, tonsillectomy, appendicectomy)
• Menorrhagia
• Post- partum haemorrhage
• Post-trauma

Question 4

When assessing a bleeding patient, what are the 3 main questions which you want to answer?

Answer 4

• Is there an emergency?
• Why is the patient bleeding?
• In cases of bleeding disorders, what is the mechanism?

Question 5

When assessing if a bleeding patient should be treated as an emergency, what would you want to establish?

Answer 5

1. Is the patient exanguinating?
2. Is there hypovolaemia?
3. Is there CNS bleeding?
4. Underlying condition which can develop from minor into catastophic haemorrhage?

Question 6

What are signs of CNS bleeding?

Answer 6

• Meningism
• CNS/Retinal signs

Question 7

What would you want to find out when trying to figure out why the patient is bleeding?

Answer 7

• Is there a secondary cause of bleeding?
• Is there unexplained bruising, bleeding or purpura?
• PMH or FH of excess bleeding?
• What is the pattern of bleeding?
• Is clotting screen abnormal?

Question 8

What are secondary causes of bleeding?

Answer 8

• Drugs
• Alcohol
• Liver disease
• Sepsis

Question 9

What tests would you do as part of a clotting screen?

Answer 9

• FBC, Platelets
• PT, APTT
• Thrombin Time
• Bleeding time
• Consider D-Dimer, Factor assays

Question 10

What are teh main patterns of bleeding which you would look for when trying to find out why someone is bleeding?

Answer 10

• Vascular
• Platelet
• Coagulation

Question 11

How would you go about trying to determine the mechanism of a suspected bleeding disorder?

Answer 11

• PT
• APTT
• Thrombin time
• D-Dimer
• Bleeding time

Question 12

What factors does the PT asses?

Answer 12

I, II, V, VII, X

Question 13

What can cause a prolonged PT?

Answer 13

• Warfarin
• Vit K Deficiency
• Liver disease
• DIC

Question 14

What factors does the APTT test?

Answer 14

I, II, V, VIII, IX, X, XI XII

Question 15

What can cause a prolonged APTT?

Answer 15

• Heparin
• Haemophilia
• DIC
• Liver disease

Question 16

What is the normal range for thrombin time?

Answer 16

10-15s

Question 17

What can cause a prolonged thrombin?

Answer 17

• Heparin
• DIC
• Dysfibrinogenaemia

Question 18

What are D-Dimers?

Answer 18

Fibrin degredation products, released from cross-linked fibrin during fibrinolysis

Question 19

When might D-Dimer be raised?

Answer 19

• DIC
• PE
• DVT
• Infection
• Malignancy

Question 20

If you found a patient to be thrombocytopenic, what tests might you consider doing?

Answer 20

• FBC
• Blood Film
• Clotting Screen

Question 21

If PT and APTT are very raised, platelets are low, and D-dimer is increased, what might be the diagnosis?

Answer 21

DIC

Question 22

What are features of a platelet bleeding disorder?

Answer 22

Bleeding from:

• Mucosal
• Epistaxis
• Purpura
• Menorrhagia
• GI

Question 23

What are features of a coagulation factor bleeding disorder?

Answer 23

Bleeding source:

• Articular
• Muscle Haematoma
• CNS

Question 24

Name platelet disorders

Answer 24

• Decreased marrow production - aplstic anamia, megaloblastic anaemia, marrow infiltration (leukaemia, myeloma), marrow suppression (chemo/drugs)
• Excess destruction - ITP, SLE, DIC
• Poorly function - myeloproliferative

Question 25

Name coagulation disorders

Answer 25

Congenital = haemophilia, von willebrand

Acquired = anticoagulants, liver disorders, DIC