Bleeding Bruising

Question 1

History of bleeding bruising

Answer 1

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

Question 2

Examination

Answer 2

Growth etc HSM/ lymphadenopathy ENT

Question 3

Investigations of bruising /bleeding

Answer 3

Fbc and film
Platelets count
APTT/PT /Fibrinogen/Thrombin time / platelets function analysis /fibrinogen

2nd line VW factor antigen/ factor 8,9,11

Question 4

Prolonged APTT alone ( PT, PFA NORMAL)

Answer 4

Factor 8 Hemophilia a
Factor 9 Hemophilia B
Factor 11 Hemophilia c
SLE
Or heparin in the central line

Question 5

Prolonged APTT AND RAISED PTA 100

Answer 5

= Von Willebrands disease (vWD)
1 vWF antigen 
Low factor 8 
Collagen binding assay 
Resothectin co factor

Question 6

Raised APPT AND PT

Answer 6

Liver disease 
Vit k def 
Lupus 
Warfarin 
DIC

Question 7

Raised PT (APTT NORMAL

Answer 7

WARFARIN

Question 8

CAUSES of normal APTT/ PTA/PT / platelet count in a child that is bruising

Answer 8

Mild vWD
Plt function defects ( normal number)
Child abuse
Self inflicted 
Vascular causes (rare)
Factor 13 def rare

Question 9

Low fibrinogen

Answer 9

Causes are DIC

And congenital hypo/absence fibrinogen

Question 10

Raised PFA

Answer 10

VWD
DRUGS. Aspirin/NSAI
UREAMIA
Platelet defects

Question 11

Hemophilia A/B

Answer 11

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

Question 12

Spontaneous haemarthroses

Answer 12

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

Question 13

Life or limb threats in Hemophilia

Answer 13

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

Question 14

Investigations of Hemophilia

Answer 14

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

Question 15

General management of Hemophillia

Answer 15

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

Question 16

Management of bleeding in hemophilia A /B

Answer 16

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

Question 17

Severe Hemophillia

Answer 17

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

Question 18

ANC diagnosis of hemophilia

Answer 18

Can do testing on male children in uterus

Question 19

VWD

Answer 19

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

Question 20

Treatment of vWD

Answer 20

Mild can try desmopressin ( DDAVP
Severe factor 8 and vWfactor
Transeximic acid in mucosal bleeding

Question 21

ITP

Answer 21

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

Question 22

Classification

Answer 22

Newly diagnosed <3/12
Persistent 3-12/12
Chronic >12/12
Plt <100

Question 23

Treatment of ITP

Answer 23

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

Question 24

Vascular causes of bruising

Answer 24

HSP
SLE
Scurvy rare
Self inflicted