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
