Bruising and Bleedign Flashcards
_______ = petechiae + ecchymoses
Purpura
Abnormal bleeding is basically the result of disorders of 1 2 3
(1) the platelet, (2) the coagulation mechanism or (3) the blood vessel
The commonest cause of an acquired bleeding
disorder is______
drug therapy (e.g. aspirin, NSAIDs, cytotoxics and oral anticoagulants
The three major mechanisms of systemic bleeding disorders are (the Virchow triad):
1 coagulation deficiencies (reduction or inhibition
of circulatory coagulation factors)
2 platelet abnormalities: of platelet number or
function
3 vascular defects: of vascular endothelium
___________ disorders which are the
most common include von Willebrand disease
(vWD), thrombocytopenia and platelet function
disorders.
Primary haemostatic
Examples of disorders of secondary
haemostasis are disorders of _____
fibrin formation and
the haemophilias
_______ present as early bleeding
following trauma
Platelet abnormalities
______ present with
delayed bleeding after initial haemostasis is
achieved by normal platelets
Coagulation factor deficiencies
A normal response to previous coagulation
stresses (e.g. dental extraction, circumcision or
pregnancy) indicates an ________
acquired problem
Drugs and their responses
__________:
— prednisolone/other steroids
vascular purpura
Drugs and their responses
______________
— cytotoxic drugs — carbamazepine — gold — sodium valproate — heparin — ranitidine — sulphonamides
thrombocytopenia
Drugs and their responses
functional platelet abnormalities:
1
2
— aspirin
— NSAIDs
The initial choice of investigations depends upon the
bleeding pattern.
If coagulation defect suspected 1 2 3 4
- prothrombin time (PT), i.e. INR
- activated partial thromboplastin time (APTT)
- fibrinogen level
- thrombin time (TT)
The initial choice of investigations depends upon the
bleeding pattern.
If platelet pathology suspected:
1
2
3
- platelet count
- skin bleeding time (of doubtful value)
- platelet function analyser (PFA-100)
The initial choice of investigations depends upon the
bleeding pattern.
If inherited disorders suspected:
1
2
3
- factor VIII
- vW factor activity
- vW factor antigen
The _______ as a screening test
of haemostasis has been shown recently to be severely
limited by its lack of specificity and sensitivity
skin-bleeding time
Laboratory investigation checklist for the easy
bruiser
Full blood count Platelet count Prothrombin time (INR) Thrombin time (TT) Activated partial thromboplastin time
A common condition is ______________ which is a self-limiting disease usually
presenting on the second or third day of life because of a
deficiency of coagulation factors dependent on vitamin
K.
haemorrhagic disease of
the newborn,
What Tx has eliminated HDN
Vit K at birth
________is the commonest of the primary platelet
disorders in children. Both acute and chronic forms
have an immunological basis
Idiopathic (immune) thrombocytopenic purpura
ITP
Prognosis of ITP
Spontaneous remission within 4 to 6
weeks occurs with acute ITP in childhood
The commonest vascular defects in childhood are:
1
2
3
• anaphylactoid (Henoch–Schönlein) purpura
• infective states
• nutritional deficiency (usually inadequate dietary
vitamin C)
_______is the commonest vasculitis of children. It affects
small vessels, producing a leucocytoclastic vasculitis
with a classic triad of non-thrombocytopenic purpura,
large joint arthritis and abdominal pain
HSP
Distribution of HSP
over the lower limbs,
extending onto the buttocks, but it can
also involve the upper limbs, trunk and even the face
The onset of HSP typically follows an upper
respiratory tract infection including a _____
group A
streptococcal tonsillopharyngitis
HSP
The bleeding time, coagulation time and platelet
counts are ______ The prognosis is ___
normal.
good; most
recover fully in a few months
Association of HSP
1
2
3
4
• Kidney involvement—deposition of IgA immune complex (a serious complication) • Melaena • Intussusception • Scrotal involvement
Tx of HSP
• Short course of steroids for \_\_\_\_\_\_ (if intussusception excluded) • If \_\_\_\_\_\_\_: follow-up urine microscopy and kidney function especially if no resolution
abdominal pain
haematuria
The purpura associated with severe infections, such
as ______ and other septicaemias, is
due primarily to a severe angiitis
meningococcaemia
Abnormal bleeding in the elderly
The outstanding causes are ____ and ______. The cause in both instances
is atrophy of the vascular supporting tissue.
senile purpura and
purpura due to steroids
This is a benign disorder occurring in otherwise
healthy women usually in their 20s or 30s. The feature
is bruising on the arms, leg and trunk with minor
trauma
Simple purpura (easy bruising syndrome
Unexplained bruising or bleeding may represent selfinflicted
abuse or abuse by others. In self-inflicted
abuse the bruising is commonly on the legs or areas
within easy reach of the patient.
Factitial purpura
ITP
The two distinct types caused by immune
destruction of the platelets are:
• acute thrombocytopenia of childhood—usually
in children, usually_____
• chronic ITP—_______ usually in
adult women; all cases should be referred to a
specialist unit
post-viral
autoimmune disorder,
Acute thrombocytopenia of
childhood:
This is caused by a reaction to a virus infection
resulting in the production of _____
cross-reacting
antibodies against platelets
Chronic ITP is a relapsing illness that rarely undergoes
spontaneous remission and may require treatment
with _______
prednisolone or biological agents e.g. rituximab
This is an uncommon life-threatening syndrome
of haemolytic anaemia, thrombocytopenia and
extremely high LDH
TTP
defect in TTP
The defect is in the absence of a specific protease in
the plasma.
The features are:
• ecchymoses
• haemarthrosis and muscle haematomas
• usually traumatic and delayed
COAGULATION DISORDERS
This is the most common disorder of haemostasis
(incidence 1% of population) and is usually a mild
problem with an excellent prognosis. There are
about 22 types
von Willebrand disease
von Willebrand disease
______ inheritance (common types
Prolonged_____
Defective platelet adhesion at site of trauma
combined with _____
Autosomal dominant
bleeding time
factor VIII deficiency
von Willebrand disease labs
- _____prolonged
- Positive ______ antigen
APTT
vW factor
menorrhagia + bruising + increased
bleeding —1. incisions 2. dental 3. mucosal
VWD
Tx of VWD
Preparations that help include desmopressin
acetate (DDAVP), factor VIII concentrates and
tranexamic acid
• Spontaneous haemarthroses, especially knees,
ankles and elbows, are almost pathognomic
• X-linked recessive pattern of inheritance
• Invariably only males affected
Haemophilia A
Haemophilia A
• Deficiency of\_\_\_\_\_\_ • \_\_\_\_\_ prolonged • Normal\_\_\_\_\_\_\_ • Many seropositive for HIV, hepatitis B or C (factor VIII concentrate transmission)
factor VIII
APTT
prothrombin time and fibrinogen
Tx of Haemophilia A
• Infusion of recombinant factor VIII concentrates
What bleeding DO
- Identical clinical features to haemophilia A
- Also an X-linked recessive hereditary disorder
- Incidence of 1 in 30 000
- Deficiency of coagulation factor IX
Haemophilia B (Christmas disease)
Tx of Haemophilia B (Christmas disease)
Treatment is with recombinant factor IX
concentrates
Main indications for Splenectomy 1 2 3 4 5
• immune thrombocytopenic purpura • haemolytic anaemias especially hereditary spherocytosis • hypersplenism • trauma • Hodgkin/non-Hodgkin lymphoma
Problem immediately after splenectomy
Immediate problem is thrombocytosis (↑ platelets
to 600–1000 × 10 9 /L) for 2–3 weeks with risk of
thromboembolism
Long-term risk is overwhelming infection
(pneumococcus [especially] ________ and ___________, especially in young children
in the first 2 years post-splenectomy
Haemophilus influenzae
and meningococcus)
Post splenectomy MX
For elective surgery give _____ at least 2 weeks before surgery
immunisation
Think of __________
in any acutely ill patient with abnormal bleeding
from sites such as the mouth or nose, venepuncture
or with widespread ecchymoses
disseminated intravascular coagulation (DIC)
Clinical situations of DIC
The clinical
situations are numerous, such as septicaemia,
obstetric emergencies, disseminated malignant
disease, falciparum malaria and snake bites
The main differential diagnoses of ACS include
aortic dissection, pericarditis, oesophageal reflux
and spasm, biliary colic and hyperventilation with
anxiety.
