Bleeding & Thrombosis Flashcards
Initial Labs to get in patients with suspected bleeding d/o
CBC
Platelet count
Peripheral Smear
D-Dimer
von Willebrand disease screen
Platelet function Analyzer
Thrombin Time
PT
PTT
Excessive bleeding does not occur in surgery or trauma patients unless platelet count is lower than what?
75,000
Platelet counts less than what are at high risk for spontaneous life-threatening hemorrhage?
5,000-10,000
What are the three broad mechanisms for developing thrombocytopenia?
Increased Destruction
Decreased Production
Sequestration
When to transfuse platelets:
stable nonbleeding patients?
Bleeding patients?
ICH or NSGY patients?
<10,000
<50,000
<100,000
Normal Dose for Platelets transfusion?
Expected response from platelet transfusion?
Duration of transfused platelets if no consumption is?
1 unit (5-pack or single donor)
increased by 20,000-30,000
3-5d
Contraindications to Platelet Transfusions?
Idiopathic thrombocytopenic purpura (ineffective)
Thrombotic thrombocytopenic purpura
Heparin induced thrombocytopenia
If a patient has rise in platelet count ~1hr after transfusion but it falls substantially 24 hrs later the patient has what going on?
This is seen in patients with what conditions?
Consumption
DIC
Sepsis
severe hemorrhage
drug-mediated immune destruction of platelets
If the patient fails to have a significant increase in platelets 1hr after transfusion the patients has what going on?
These patients may have what conditions?
Destruction
Hypersplenism
Autoantibody that eliminates endogenous platelets but also allogenic platelets (as in ITP)
Alloantibodies that react with antigens on transfused platelets
Most frequent cause of cytopenias is?
Thrombocytopenia w/n days to weeks following initiation of a new drug is highly suggestive of what?
drug induced thrombocytopenia
Heparin Induced Thrombocytopenia
Antibody development activates platelets following what?
What % of patients develop thrombosis if left untreated?
May develop what? and require what?
Mortality rate in patients with HIT?
Platelets will drop how low in how long?
heparin exposure
~38-76%
gangrenous limbs that require amputation
30%
<100,000 or 50% from baseline w/n 5-1 days
What Score will help calculate probability of HIT?
4T test
What Lab tests can be ordered to diagnose HIT?
LIA test
ELISA test
SRA test
If HIT is suspected what actions should be made?
Stop all heparin immediately
Alternative anticoagulation should be administered
Hematology c/s
What alternative anticoagulation should be used if HIT is suspected?
Direct thrombin inhibitor (Argatroban or Bivalirudin)
DOACs
Clinical Manifestations of ITP
ITP can occur in patients of what sex? and what age?
Most adults with this disease experience what?
Thrombocytopenia and bleeding typically occurs where?
Patients typically experience this as well?
either sex; any age
chronic, recurring disorder
skin mucous membranes
fatigue
ITP patients can experience bleeding where?
epistaxis
gingival bleeding
hematuria
melena
excessive vaginal bleeding
bruising
Physical exam should pay particular attention to signs of mucocutaneous bleeding or hemorrhage w/n what?
the conjunctiva
retina
CNS
ITP Diagnosis includes?
Hx/Physical (Bleeding symptoms, recent infections, underlying conditions)
CBC (Thrombocytopenia, Peripheral Smear remarkable only for decreased # of platelets, some of which may be larger than normal)
Coags
HIV and HCV
Immunologic (Consider ANA, TSH)
Treatment
1st line?
Secondary Treatments?
Corticosteroids
IVIG
Anti-Rho(D)
Thrombopoietin receptor agonists
Corticosteroids to give for ITP and their dose?
Prednisone 1-2mg/kg/day
Methylprenisolone 1gm/day IV
Dexamethasone 40mg/day x 4days
ITP dosing for IVIG
2 days?
5 days?
Response rates are typically?
Effects last how long?
Toxicity sx include?
1g/kg/day
0.4g/kg/day
2-4wks
HA, allergic rxs, rarely thrombosis
ITP Thrombopoietin Receptor Agonists and their doses?
Romiplostim 1-10mcg/kg/dose SC qwk
Eltombopag 50-75mg PO qd
Avatrombopag 20-40mg PO qd
Thrombotic Thrombocytopenic Purpura Classic Symptoms
Thrombocytopenia
Anemia
Fever
Neurological Problems
Renal abnormalities
TTP Clinical Manifestations
What patient populations?
Patients may present with what two types of conditions?
May c/o what? (presumably d/t what?)
Signs of CNS dz such as what can be seen?
Two major hallmarks of TTP are what?
Unlike most patients with typical thrombocytopenia, who tend to bleed excessively patients with TTP have what?
Instead they are markedly predisposed to what?
May be associated with what?
Young, adult, female, black and overweight
mucocutaneous bleeding or a thrombotic event (Phlebitis, MI or stroke)
abdominal pain (intestinal ischemia)
macroangiopathic hemolytic anemia caused by RBC fragmentation and thrombocytopenia
few hemorrhagic complications
thrombosis
autoimmune d/o
TTP Labs to get?
CBC (anemia and thrombocytopenia)
Peripheral Smear (Schistocytes, nucleated RBC, aniosopikilocytosis, megaloblastic changes, teardrop cells)
Reticulocyte count (elevated)
LDH (elevated)
Indirect Bilirubin (elevated)
haptoglobin (decreased)
coags (normal)
fibrinogen
d-dimer (elevated)
direct antiglobulin test (negative)
ADAMS13activity
BMP (+/- elevated Cr)
TTP check a Plasmic Score:
Platelet count?
Hemolysis (recticulocyte count? haptoglobin? indirect bilirubin?)
cancer?
organ or stem cell transplant?
MCV?
INR?
Cr?
< 30,000
>2.5%; undetectable; >2 mg/dL
no active cancer
no organ or stem cell transplant
<90 fL
< 1
<2 mg/dL
Plasmic Scores and what they indicate?
0-4?
5?
6-7?
risk of TTP?
low risk
intermediate risk
high risk
Treatment of TTP includes?
PLEX with FFP transfusions is treatment of choice
Glucocorticoids
Caplacizumab
Rituximab (off label use)
Follow LDH, Hgb, Plt
PLEX with FFP transfusions for TTP
Has what effects?
Monitoring should include?
When can PLEX be dc?
removes pathogenic antibodies and repletes deficiency of ADAMTS13
CBC, LDH, retic count, and Cr
After hemolysis has been corrected for a few days
TTP Glucocorticoid and doses?
Methylprednisolone 1g/dx3 days (high risk pts)
Prednisone 1mg/kg/d (standard risk)
TTP Caplicizumab (anti-vWF fragment)
Day 1 dose?
followed by what dose for how long?
10mg IV
10mg SC x 30 days
Clinical Manifestations of Hemolytic Uremic Syndrome?
Abdominal pain
N/V
diarrhea
ecchymosis
AKI
Labs to get for Hemolytic Uremic Syndrome?
CBC (anemia and thrombocytopenia)
Peripheral Smear (schistocytes)
LDH (elevated)
Indirect Bilirubin (elevated)
Haptoglobin (decreased)
Coags (normal)
Fibrinogen
D-dimer (elevated)
direct antiglobulin test (negative)
BMP (elevated Cr)
UA (hematuria and proteinuria)
complement H autoantibody levels
stool culture
Hemolytic Uremic Syndrome Treatment:
Supportive care including what?
Plasmapheresis may be beneficial in what type caused by dysregulation of complement?
Eculizumab or Ravulizumab (anti-C5, antibody that inhibits the terminal step in the complement cascade) for what forms?
if indicated use what?
dialysis
atypical forms
atypical forms
HD
von Willebrand Disease Clinical Manifestations include?
Mucocutaneous bleeding symptoms
easy bruising
prolonged or excessive bleeding from minor cuts or other injuries
nosebleeds or other mucosal bleeding
GI hemorrhage
Heavy Menstrual Bleeding
Increased risk for bleeding after surgery or invasive procedures
Sx can range from mild or infrequent bleeding to severe-life threatening bleeding
Diagnostic Tests for von Willebrand disease
VWF antigen and VWF activity/antigen ratio
VWF activity: ristocetin cofactor activity (VWF;Rco), levels < 30 are diagnostic for VWD
Factor VIII coagulant activity (decreased)
CBC, Coags (prolonged PTT)
VWD Treatment
c/s who?
Prevention of what?
give what to help increase plasma levels of VWF and augments aggregation?
Other treatments include?
Hematology
bleeding episodes
desmopressin 0.3mcg/kg (DDAVP)
Recombinant VWF, VWF concentrate
Cryoprecipitate
OCP
VWD Major bleeding or Surgery Recombinant VWF:
Initial dose?
Followed up by what dose how often?
VWF levels should be kept where for how long?
50-80 IU/kg
40-60 IU/kg q 8-24 hrs
50-100 IU/kg for 2-3 days or longer
VWD Minor bleeding or surgery Recombinant VWF:
Initial dose?
Followed up by what dose how often?
40-50 IU/kg
40-50 IU/kg q8-24 hrs as needed clinically
VWD Major surgery/bleeding VWF concentrate
Loading dose?
Maintenance dose?
40-60 U/kg
20-40 U/kg q8-24hrs
VWD Minor surgery/bleeding VWF concentrate
Loading dose?
Maintenance dose?
30-60 U/kg
20-40 U/kg q12-48hrs
Hemophilia’s Clinical Manifestations
Spontaneous bleeding
IM hematomas
compartment syndrome
excessive bleeding with trauma or surgery
hematuria
GI bleeding
Hemophilia’s can present with Hemarthrosis, what does this look like on PE?
the joint is swollen, hot and tender to palpation, with erythema of the overlying skin.
Join mobility is compromised by pain and stiffness, and the joint is usually maintained in a flexed position
Hemophilia’s can present with what problem in newborns and adults?
ICH
Diagnosis of Hemophilia’s includes
Hx?
Prolonged what with normal what? other studies to get?
c/w Hemophilia A?
c/w Hemophilia B?
Family or personal bleeding hx
Prolonged PTT w/ normal PT, mixing study, coagulation factor specific assays
Deficiency in Factor VIII
Deficiency in Factor IX
Treatment of Hemophilia
c/s who?
Prior to surgery give what for Hemophilia A? give what for Hemophilia B?
Mild to moderate Hemophilia A patients can receive what to increase plasma levels of Factor VIII and VWF?
Antifibrinolytic agents to give?
Hematology
Factor VIII concentrate; Factor XI concentrate
DDAVP
TXA or aminocaproic acid
