Bleeding and clotting

Question 1

What are the 3 categories of bleeding disorder?.

Answer 1

1) Vascular defects
2) Platelet disorders
3) Coagulation disorders

Question 2

How is the pattern of bleeding different in the different bleeding disorders?

Answer 2

Vascular defects and platelet disorders cause prolonged bleeding from cuts, bleeding into skin (easy bruising and purpura) and bleeding from mucous membranes (epistaxis, bleeding gums, menorrhagia).

Coagulation disorders cause delayed bleeding into muscles and joints.

Question 3

Which factor is deficient in Haemophilia A?

Answer 3

VIII

Question 4

How do we manage Haemophilia A?

Answer 4

Avoid NSAIDs and IM injections.
For minor bleeding: pressure and elevation
Desmopressin can increase Factor VIII levels (by increasing vWF).
Major bleeds (e.g. haemarthrosis): increase factor VIII to 50% of normal.
Life-threatening bleeds (e.g. causing airway obstruction): increase factor VIII to 100% of normal e.g. using recombinant factor VIII.

Question 5

What factor is deficient in Haemophilia B?

Answer 5

IX (Christmas factor)

Question 6

What is acquired haemophilia?

Answer 6

Sudden appearance of autoantibodies interfering with factor VIII. Causes big mucosal bleeds. Present in both males and females.

Question 7

How do we treat acquired haemophilia?

Answer 7

Steroids

Question 8

What prolongs prothrombin time (PT)?

Answer 8

Warfarin, vit K deficiency, liver disease, DIC.

Question 9

Which part of the clotting cascade does APTT test?

Answer 9

Intrinsic

Question 10

What prolongs APTT?

Answer 10

Heparin, haemophilia, liver disease, DIC

Question 11

What causes a raised D-dimer?

Answer 11

DVT/PE, DIC, inflammation (e.g. infection or malignancy)

Question 12

When is bleeding time increased?

Answer 12

von Willibrand’s disease, platelet disorders, low-dose aspirin (not full dose aspirin).

Question 13

Transfusion of 1 unit of red cells increases Hb by how much?

Answer 13

10-15g/L

Question 14

When is FFP transfused?

Answer 14

Clotting defects (e.g. DIC), warfarin overdose where vitamin K would be too slow, liver disease, TTP.

Question 15

What is the target INR when warfarin is given to prevent stroke in patients with prosthetic metallic heart valves?

Answer 15

3-4

Question 16

Is longterm anticoagulation given to all patients with thrombophilias?

Answer 16

No. If asymptomatic then this is not necessary. Need to advise them of the risk of VTE, don’t give the Pill or HRT. Prophylaxis may be needed in pregnancy (with heparin and aspirin as warfarin is teratogenic).

Question 17

How do we treat acute thrombosis?

Answer 17

Heparin, then warfarin to target INR of 2-3.
If recurrence occurs then lifelong warfarin may be considered.
Recurrence whilst on warfarin should be treated by increasing target INR to 3-4.

Question 18

In which thrombophilia might you see skin necrosis (especially if given warfarin)?

Answer 18

Protein C or S deficiency