Approach to the Bleeding Patient Flashcards
Why do patients bleed?
-Primarily hemostatic disorders
-hemorrhage from mass
-gastrointestinal ulceration
-parasitism
-trauma
-iatrogenic/pharmacologic
-toxins: xylitol causing liver failure, anticoagulant rodenticide
What differentials are possible for dyspnea in a dog?
-pharyngeal/laryngeal disease
-pulmonary disease
-pleural space disease
-cardiac disease
-mediastinal mass
-hemorrhage
What differentials are possible with multifocal bleeding?
-trauma
-coagulopathy/primary hemostatic disorder
What differentials are possible with lameness/MSK pain?
-trauma
-foreign body
-coagulopathy/primary metastatic disorder
-neoplasia
What are the main things that can greatly prolong PT/PTT?
-anticoagulant rodenticide (will result in the most severe increases)
-liver failure
-DIC
-primary clotting disorder
Why is fresh frozen plasma the first thing grabbed in anticoagulant rodenticide cases if the patient is not yet anemic?
It contains clotting factors
-blood also contains clotting factors, but is not needed if the patient is normovolemic
What is the first factor affected by anticoagulant rodenticide?
Factor 7 -PT is therefore prolonged before PTT
- PT assesses the extrinsic pathway
Also affects factor 2, 9 and 10
- when both pathways are affected, this is where you see spontaneous bleeding
How many days should a dog receive vitamin K therapy in a case of anticoagulant rodenticide?
28-30 days
What are the differentials for petechiation?
Thrombocytopenia, Thrombocytopathia, Endothelial dysfunction
At what platelet value can you see spontaneous hemorrhage?
30-50,000
-hemorrhage most commonly occurs at skin and GI tract
What are the differentials of destructive, decreased production, consumptive and sequestration based thrombocytopenia?
Destructive: infectious disease, immune mediated, neoplasia, inflammatory disorders, drug induced
Decreased production: myelodysplastic disorders, drug induced, immune mediated, infectious agents, hereditary
Consumptive: DIC, Vasculitis, envenomation, thrombosis
Sequestration: splenomegaly, vasculitis
- usually secondary to other problems
What differential causes the most severe decreases in platelet numbers?
IMTP
-diagnosed through ruling everything else out
What blood products should you give in IMTP patients that are losing blood?
Whole blood- BEST to replenish all of the lost components of blood
- dont just give platelets- not a lot of good evidence in veterinary medicine
What are the different treatment options for IMTP?
Whole blood, Corticosteroids (2 mg/kg), secondary and tertiary immunosuppressants (azathioprine, cyclosporine, mycophenolate), vincristine, human immunoglobulins (when other options arent helping-very expensive)
-can also give sucralfate and omeprazole as they are prone to ulceration (need to give 2X per day- evidence this is superior to famotidine)
What are the side effects of steroids?
PUPD, excessive hunger, panting, agitation/abnormal behavior
-essentially cushings signs
Which is superior of the secondary and tertiary immunosuppressants?
No literature really supports any being better
-all have risk of causing GI effects
- azathioprine and cyclosporine can cause liver changes
What is the mechanism of action of vincristine in IMTP cases?
It is a chemotherapy agent that stimulates bone marrow to release megakaryocytes sooner, thus replacing lost platelets
- provides some relief to decrease bleeding
Also interferes with immune mechanisms that cause platelets to be targeted for destruction
T/F: Primary IMTP in cats is very rare
True
- if it happens it is usually a secondary problem, usually still rare
What is the normal platelet count for a dog with primary IMTP?
<10,000
If between 10,000-50,000 it is usually secondary (infectious causes, drug effects, neoplasia, sequestration in spleen, vasculitis)
T/F: the higher the platelet count and the lower the Hct the worse the outcome in IMTP cases
False- lower platelet counts associated with worse outcomes
Why can you not trust analyzers to report an accurate platelet count in cats?
The platelets in cat blood clump significantly
- need to do a manual count
What are some differentials for pleural effusion?
Cardiac, neoplasia, chronic pericardial effusion, hepatic/renal disease, diaphragmatic hernia, lung lobe torsion, thrombus, heartworm
What are some differentials for pericardial effusion?
-neoplastic rupture
-pericarditis
-coagulopathy/thrombocytopathia
-infectious
-left atrial rupture
What are the only differentials for a regenerative anemia?
Hemorrhage or hemolysis
T/F: liver elevations always need to worry you in a cat
True- even mild changes are often significant
- liver enzymes never get that high in cats
In a case of chronic bleeding into the lungs/pericardium, why may total solids not drop?
If globulins are high (due to cancer or infection/inflammation), if the patient is very dehydrated
What blood product is preferred in cases of internal blood loss?
Whole blood
- very rare to find for a cat
What are some differentials for hematochezia/hematemesis?
AHDS/HGE, intestinal parasitism, GI ulceration, endocrinopathy (addisons), coagulopathy
How can you diagnose HGE? How long does it take to resolve with supportive care?
Only by ruling everything else out
Takes up to a week to resolve
- do not add on metronidazole- does not work
Why is it not recommended anymore to change the diet in GI cases?
Could make the GI upset worse
- hard to determine if the GI upset is newly related to food change or it is due to the dog not getting over diagnosis in hospital
- if you do anything, add pumpkin
