Bleeding Bruising Flashcards
History of bleeding bruising
1 Spontaneous vs traumatic
2 Site of the bleeding
Below the knees common non palpable, small only sites
Arms/ face, trunk, buttocks significant palpable large
3 sites gums/nose/ mouth/buttocks/ bowel/ joints/muscle 4 history of birth trauma 5 immunizations/venesection Surgery ent. Circumscions/ ent Medications Family history
Examination
Growth etc HSM/ lymphadenopathy ENT
Investigations of bruising /bleeding
Fbc and film
Platelets count
APTT/PT /Fibrinogen/Thrombin time / platelets function analysis /fibrinogen
2nd line VW factor antigen/ factor 8,9,11
Prolonged APTT alone ( PT, PFA NORMAL)
Factor 8 Hemophilia a Factor 9 Hemophilia B Factor 11 Hemophilia c SLE Or heparin in the central line
Prolonged APTT AND RAISED PTA 100
= Von Willebrands disease (vWD) 1 vWF antigen Low factor 8 Collagen binding assay Resothectin co factor
Raised APPT AND PT
Liver disease Vit k def Lupus Warfarin DIC
Raised PT (APTT NORMAL
WARFARIN
CAUSES of normal APTT/ PTA/PT / platelet count in a child that is bruising
Mild vWD Plt function defects ( normal number) Child abuse Self inflicted Vascular causes (rare) Factor 13 def rare
Low fibrinogen
Causes are DIC
And congenital hypo/absence fibrinogen
Raised PFA
VWD
DRUGS. Aspirin/NSAI
UREAMIA
Platelet defects
Hemophilia A/B
Most common congenital bleeding disorder in NEWBORN /Infats
X linked recessive (boys mostly occas girls)
A and B have identical features
Severity mild 5-49% mod <5 and severe <1% u complete absence of the factor
Hemophilia A (80% def of Factor 8)
1/3 NO family history
Factor 8 links to vW factor
Can present with a clinically significant bleed in the first year of life
Birth trauma subgleal hemorrhage’s spontaneous intracranial haem
Oral / multiple soft palpable bruises
Spontaneous haemarthroses
Joint bleed synovial bleeding happens in Hemophilia
Early signs. Child says it feels like previous bleeds in the joint ) older child
Limp wont weight bear
Swelling pain warmth loss of movement
Recurrent bleeding damages the joint TARGET joint chronic damage
Life or limb threats in Hemophilia
1 intracranial bleeding in the neonatal period can present with spontaneous hemorrhage with minimal trauma CTscan
2 haem into muscles in the arm/leg compartment syndrome USS
3 soft tissue of the neck. Laryngeal obstruction uss
Investigations of Hemophilia
Fbc film PT APTT PFA Factor 8,9, vW factor antigen
Test other family members
Mother check factor 8 may be normal
ANC diagnosis
Genetic testing
USS of the joints if ? Acute bleed MRI for long term
CNS bleed CT scan
General management of Hemophillia
1 no aspirin
2 alert braclet
3 no IMI injections
4 no contact sport no headers in soccer / no rugby
5 dental checkups ( aim is to avoid dental extractions)
6 monitor viral infections
7 watch for the development of inhibitors
De
Management of bleeding in hemophilia A /B
Replace factor 8/9
Joint bleeding RICE and analgesia
Some haemophilia A (>7% mild ) response to desmopressin useful for mild bleeds or tooth extraction ( need to test before see that it works
Don’t use desmopressin <2years
Severe Hemophillia
Need prophylaxis to prevent the arthropltic changes
Severe <1% factor 8 ( 3 x per week )A/ factor 9 B ( treatment 2x per week)
Disadvantages Central line Sepsis thrombosis death
Start about 2 years of age or from the first joint bleed
Develope an inhibitor 33% by 6 years
Treat with daily factor 8 70% respond to that
ANC diagnosis of hemophilia
Can do testing on male children in uterus
VWD
Commonest inherited coag disorder
Autosomal dominant
Qant and qualitative defects in vW factor
VW factor assist adhesion of plt to the bleeding site
VW factor protects factor 8
Type 1 vWD hard to diagnose
Epistaxsis /menorrhagia / easy bruising dental extraction problems
Lab results DIFFICULT levels vary with bleeding, pregnancy exercise/ drugs periods
Can see raised APTT / raised PFA factor 8 low / vWfactor Antigen low
Collagen binding low ristorante co factor low
Can be normal esp if the person is bleeding
Treatment of vWD
Mild can try desmopressin ( DDAVP
Severe factor 8 and vWfactor
Transeximic acid in mucosal bleeding
ITP
Immune thrombopenia
Sudden or insidious bruising or Petiche +/- bleeding
80% preceding viral illness
Low platelet count normal HB( unless heavy bleeding ) Normal WCC
MCV normal no HSM or lymphadenopathy
High MCV alarm bells something else
Cause of low platelet count
Artifact taking the blood from a central line
Pathophy. Autoimmune plus ab to megakarocytes
Classification
Newly diagnosed <3/12
Persistent 3-12/12
Chronic >12/12
Plt <100
Treatment of ITP
Controversial
1 treat the clinical picture ie if the child is bleeding ( not petichae / bruising)
2 treat if <20 platelet
90% spontaneous resolution by 12/12
Intracranial haem is the big worry
Treatment
Prednisone short course if use ( avoid prolonged steroids)
IVIG esp for acute bleeding
Other treatment 2nd line
Vascular causes of bruising
HSP
SLE
Scurvy rare
Self inflicted
