Bleeding

Question 1

what are platelet disorders the result of?

Answer 1

either thrombocytopenia or disorders of platelet function
thrombocytopenia: deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury.

Question 2

What does ITP stand for?

Answer 2

immune thrombocytopenic purpura

there is immune destruction of platelets

Question 3

purpura

Answer 3

rash of purple spots on the skin caused by internal bleeding from small blood vessels

Question 4

ITP in children

Answer 4

follows viral infection

rapid onset of purpura, usually self lmiting

Question 5

ITP in adults

Answer 5

less acute
young women
may occur with other AI disorders, in patients with CLL and after infection with some viruses

fluctuating course, with easy bruising, epistaxis (nosebleeds) and menorrhagia

Question 6

Ix ITP

Answer 6

thrombocytopenia with normal or increased megakaryocytic on BM Ex

detection of platelet antibodies (present in 60-70%) isn’t essential for Dx

Question 7

1st line Tx for ITP

Answer 7

oral corticosteroids

relapse is common when the dose is reduced

useful before surgery, when rapid platelet count is needed

Question 8

2nd line Tx for ITP

Answer 8

splenectomy, to which the majority of patients respond

Question 9

TTP

Answer 9

thrombotic thrombocytopenic purpura

widespread adhesion + aggregation of platelets –> microvascular thrombosis and profound thrombocytopenia

Question 10

TTP cause

Answer 10

congenital, sporadic or autoantibody mediated deficiency of ADAMTS 13, a protease normally responsible for the degradation of vWF

Question 11

Presentation TTP

Answer 11

florid purpura
fever
fluctuating cerebral dysfunction
haemolytic anaemia with red cell fragmentation
renal failure

Question 12

Coagulation screen TTP

Answer 12

usually normal

lactate dehydrogenase levels are raised from haemolysis

Question 13

Tx TTP

Answer 13

plasma exchange (to remove antibody to ADAMTS 13)
methypredisolone
rituximab

Question 14

what is disseminated intravascular coagulation

Answer 14

widespread activation of the clotting cascade –> blood clots in the small vessels throughout the body

compromise of tissue BF –> multi organ damage

coagulation process consumes clotting factors and platelets –> normal clotting is disrupted and severe bleeding occurs from various sites.

Question 15

cause of DIC

Answer 15

massive activation of the clotting cascade

To do with release/expression/exposure of tissue factor

common causes: sepsis, major trauma, tissue destruction, cancer

Question 16

clinical features DIC

Answer 16

varies from no bleeding to complete haemostatic failure, with bleeding from venipuncture sites, nose and mouth

Question 17

Ix DIC

Answer 17

Hx, clinical presentation and severe thrombocytopenia

confirmed by: prolonged PT, APTT and TT, decreased fibrinogen and elevated FDPs

fragmented red cells

Question 18

Mx DIC

Answer 18

Treat underlying condition

Platelets concentrates

Question 19

contraindications for warfarin

Answer 19

peptic ulcer
bleeding disorder
severe hypertension
pregnancy

care: elderly, previous GI bleed

Question 20

what is the target INR?

Answer 20

between 2 and 3

Question 21

why give vitamin K to those on warfarin?

Answer 21

warfarin inhibits the reductase enzyme responsible for regenerating the active form of vitamin K, producing a state a bit like vit K deficiency

Question 22

what has an initial prothrombic effect?

Answer 22

warfarin! so continue heparin over until warfarin’s “settled”