Bleeding 1 and 2 Flashcards
What does a hemodynamically unstable patient look like?
Tachycardia, pale gums, altered mentation, hypothermic, may be febrile
Why could a patient be bleeding?
Primary hemostatic disorders, hemorrhage from mass (neoplasia), GI ulcerations (rimydyl), parasitism (fleas), traumatic, iatrogenic/pharmacological, toxin (xylato, sagal palm, rodentacide)
Case 1: Asher
Hisotry:
Difficulty breathing
Wound thorax
Forelimb lameness
Hepatic abscesses in past (lobectomy)
UTP vac
Free Range Property
PE:
Dyspnea, hemorrhagic sublingual and laryngeal saccule swelling, hemorrhage hard palate, elbow pain and swelling, abrasion right axillary with continuous bleeding
What are you differentials?
Anemia - Difficulty breathing, hemorrhage, liver damage
-Coagulation Disorder
-Toxin (rodenticide)
-Trauma
-Pharyngeal or laryngeal disease
-Pulmonary disease
-Cardiac disease
Forelimb lameness, wound thorax - trauma
-Neoplastic
-Coagulopathy
Swelling soft palate
-Ate a toxin or FB
What diagnostics would you recommend for Asher?
CBC
Chem
Clotting Times
X-ray or Ultrasound (Thoracic/Abdomen)
Results from diagnostics:
CBC: Normal
Chem: Normal
Thoracic X-ray: Cranial mediastinal Mass Effect (rule out neoplasia)
PTT: Increased
PT: Increased
What is higher on the differential list for Asher now?
Clotting Disorder
Toxicity
What are some of the major components of hemostasis?
Vascular Injury
-Vasoconstriction
-Collagen -> platelet activation ->vwf and fibrinogen help from a platelet plug (primary hemostasis)
-Tissue factor -> Coagulation cascade -> throbin that turns fibrinogen to fibrin to make a blood clot (secondary hemostasis)
-Antithrombotic control mechanism
Which clotting factors are part of the Intrinsic pathway? Extrinsic?
Common?
Intrinsic: XII, XI, IX, VIII (PT)
Extrinsic: III, VII, X,
Common: II, I
Which clotting factor does rodenticide effect?
Factor 7 - vitamin K dependent (2, 10, 9)
What is the treatment for Asher and his rodenticide positioning?
Vitamin K Oral or SQ
Plasma (give clotting factors we are missing)
Oxygen
Pain Management
What is the difference between the 3 main blood products and what are they?
Whole Blood - Fresh (8hrs) or stored (3-4wk)- no functional platelets, hypovolemic patient with coagulopathies, won’t get sustained platelet function
Packed Red Cells - pRBC 21 day shelf life, normovolemic, anemic patient
Frozen Plasma - FFP frozen, all coag factor and protein, < year, all coagulopathies, Stored frozen, rodenticide and hypoproteinemia
How long should Asher be treated with vitamin K?
30 days, or until he fully recovers
-Recheck PT/PTT 48-72 hours after completion vitamin K
Asher represent with pale MM, delayed CRT, dull mentation, weakness, abdominal fluid wave (shock)
Diagnostics: Ultrasound - abdominal mass effect
CBC: Normochromic, normocytic anemia, neutrophilia, lymphopenia, monocytosis, thrombocytopenia, low protien
Chem: Hyperglycemia, hyperphosphatemia, protenemia, high ck, low sodium and chloride
Poor clotting times
PCV abdominal fluid 30%
What is going on? What are your differentials?
Hemorrhage in the abdomen
-Trauma
-Coagulopathy
-Neoplasia
How would you treat Asher during his second visit?
Whole blood
(FPP and RBC if no whole blood)
Vitamin K orally (28 more days)
CT scan look neoplastic
Advanced antigoagulopahty testing considered
Case 2: Molly
HX:
Hyporoxia, dental 1 week ago
Strong pulse, pale MM, mumur, petechiation, UTD vac and preventative
meloxicam and gabapentin
PE:
Petechia
Staining/red nose
belly dark staining
What is Mollys problem list?
Petechia
Pale MM
Heart Murmur
Lethargy
Hyperoxia
What is on Mollys Differential list?
Anemia - hemolysis, heart disease, tick borne illness
Thrombocytopenia - SPUD
What diagnostics should be recommended for Molly?
CBC
Chem
Coagulation
Mollys Diagnostics
CBC: Low PCV, Low RBC, Low Platelet, Protein normal
What are the differentials for Thrombocytopenia?
Destruction - infectious disease, immune mediated, neoiplasma, inflammatory, drug
Decreased Production- Myelodysplastic, drug, immune, infecitous, heredity
Consumptive - DIC, vasculitis, envenomation, thrombosis
Sequestration - Splenomegaly, vasculitis
What is most likely to cause an extremely low platelet count?
Immune Mediated Thrombocytopenia
An ultrasound was performed on Molly:
-Hyperchoic liver nodule, splenomegaly
Rads: NSF
4DX: Negative
PCR panel - negative
What is your diagnosis?
Immune mediated thrombocytopenia
What would you treat molly with?
Immunosuppressants
Molly went home on the immune suppressants but had worsening lethargy, anorexia, vomiting and petechia and melaena
What could be going on now?
GI hemorrhage
Molly now had pale MM, dehydration of 5-7%, weak and stumbling, bruising and melena.
PCV decrease TS decrease. What may be going on?
Serious Hemorrhage
What blood product would you give molly if she is experiencing serious hemorrhage?
Whole blood
What other treatments would molly need in addition to whole blood?
Sucralfate, omeprazole
Steroids
Secondary or teritary immunosupressants (Azathioprine, cyclosporine, mcophenolate)
Vincristine
Human Immunoglobulins
Case 3: Darwin
Lethargy, tachypnea, hyprexia
Pale MM, muffled heart sound and lung sound
Pleural and pericardial effusion, thoracentesis fluid modified transudate
UTD vaccine and prevention
Rads: Cranioventral effusion, prominent vascular pattern
PCV low normal TS normal
Platelet low - clump in cat
What is the problem list and differentials?
Pericardial Effusion: neoplastic rupture, pericarditis, cardiac, coagulopahty, infection, rupture
Pleural effusion: cardiac, neoplasia, chronic, hepatic, hernis, lobe torsion, thrombus, heartworm
Regenerative: Hemorrhage or hemolysis
Pleural Effusion
Regenerative Anemia
Ultrasound was performed and pleural fluid was tapped to reveal chronic active hemorrhage. A mass was observed. So why did his hemorrhage not decrease protiens?
Neoplasma increase globiulin
What treatments should darwin receive?
Centesis
Blood transfusion (whole)
Fluids
Euthanasia
Case 5: Freya
Hematochezia, hematemesis with blood clot, vomiting, diarrhea, hepatopathy
What do you already suspect?
Blood loss or hemorrhage
What are some differentials for bloody vomit and diarrhea?
HGE, Ulcer, gastric neoplasia, FB, coagulation disorder
What diagnostics would you run?
CBC and Chem
Ultrasound or Xray
Diagnostic Results:
Normal PCV and TS
Liver values high
Cortisol increased
Where does that leave us?
Not Addison’s
Not coagulopathy
May be HGE
What treatments should be used for HGE?
IVF, cerenia, sucralfate, pantoprazole
SQF, cerneia, sucralfate pantoprazole
