Bruising And Bleeding

Question 1

Major causes of bleeding disorders

Answer 1

. Structural
. Platelet-related
. Clotting factor-related (platelet plug not stable)

Question 2

Leukemia

Answer 2

. Group of neoplasticism disorders affecting leukopoietic tissues in body
. Characterized by leukocytosis, immature leukocytes in peripheral blood
. Proliferation of immature cells in marrow suppressing normal cell growth (like MK cells)

Question 3

Idiopathic thrombocytopenic purpura

Answer 3

. Platelet destruction inc. from circulating antiplatelet antibodies in plasma
. Platelet survival is shortened

Question 4

Hemophilia A/B

Answer 4

. Genetic defect x-linked recessive
. Inc. bleeding from clotting disturbance
. 70% people are inherited, others from spontaneous mutation
. A is deficiency in factor VIII, b from IX deficiency

Question 5

Disseminated intramuscular coagulopathy

Answer 5

. Systemic activation of blood coag resulting in generation and deposition of fibrin
. Leads to microvascular thrombi in organs causing dysfunction
. Possible consumption and subsequence exhaustion of coag proteins and platelets may cause severe bleeding

Question 6

Diascopy

Answer 6

. Test for blanchability by applying pressure w/ finger and observing color change

Question 7

Normal platelet count

Answer 7

. 150,000-400,000
. Thrombocytopenic: less than 150,000
. Thrombocytosis: over 400,000

Question 8

Partial thromboplastin time

Answer 8

.blood test evaluating integrity of intrinsic and common coag pathway and to monitor patients on Heparin
. Normal 25-37 s.

Question 9

Prothrombin time

Answer 9

. Blood test that measures how quickly blood clots

. Normal 10-14 s.

Question 10

International normalized ratio (INR)

Answer 10

. 1.1 or below is normal

. 2-3 is therapeutic range when taking blood thinners

Question 11

Bleeding time (BT)

Answer 11

. Standard filter paper should be every 30 s. Until blood completely stops
. Normal: 2-9 minutes
. Risk of bleeding inc. w/ time over 10 min.

Question 12

Unexplained nosebleeds suggest ___

Answer 12

. Platelet defects

Question 13

5 causes of dec. platelet production

Answer 13

. Meds
. Bone marrow replacement by malignancy, fibrosis, or granulomas 
. Bone marrow aplasia
. Alcohol 
. B12 deficiency

Question 14

5 causes of inc. platelet consumption

Answer 14

. Splenic sequestration 
. Autoimmune thrombocytopenia (idiopathic, HIV, lupus, lymphoproliferative issues, meds)  
. Disseminated intravascular coag. 
. Thrombotic thrombocytopenic pupura
. Sepsis

Question 15

Evaluation of bleeding patient

Answer 15

. Clinical context (post-surgical, sepsis, exposure to anticoags)
. Personal history (onset in infancy = heritable condition, as adults = milder heritable condition or acquired cause)
. Family history
. Location (mucocutaneous bleeding = suggests qualitative/quantitative platelet defects, joint/soft tissue= disorders of coag factors

Question 16

Platelets

Answer 16

. Critical role in hemostasis

. Functions: adhesion, activation, aggregation

Question 17

Bernard-soulier syndrome

Answer 17

. Deficiency in GpIb platelet Factor

Question 18

Glanzmann thrombasthenia

Answer 18

. Deficiency in GpIIb-IIIa complex in platelet clotting

Question 19

Von willebrand Disease

Answer 19

. Most common inherited bleeding disorder, most cases autosomal dominant
. Due to issues w/ Von willebrand factor (glycoprotein that binds platelets to subendothelium and is a carrier of factor VIII)

Question 20

Type I Von willebrand disease

Answer 20

. Type i: 75-80% pts, mild to moderate bleeding, don’t bleed spontaneously, involves skin and mucous membranes
. Keep in mind for teen patients
. Normally diagnosed when excessive bleeding occurs after procedure, heavy or long menstrual bleeding (changing of pad once an hour)

Question 21

Type II Von willebrand disease

Answer 21

. 15-20% patients
. Moderate to severe bleeding
. Usually present in childhood or adolescence

Question 22

Type 3 Von willebrand disease

Answer 22

. Severe bleeding in infancy and childhood

. Autosomal recessive inheritance

Question 23

Bernard-Soulier syndrome

Answer 23

. Autosomal recessive inheritance
. Reduced or abnormal platelet membrane expression of GIb/IX
. Failure of adhesion
. Severity of symptoms vary
. Clinical features: petechia, ecchymosis, recurrent epistaxis

Question 24

Glanszmann’s thrombasthenia

Answer 24

. Autosomal recessive
. Platelets contain low or defective glycoprotein GpIIb/IIa (fibrinogen receptor)
. Platelets aggregation impaired os no thrombus formation
. Clinical features: petechia, ecchymosis, recurrent epistaxis

Question 25

Idiopathic thrombocytopenia

Answer 25

. Acquired disorder
. Immune mediated destruction of platelets (antibodies against. Platelet membrane antigens)
. Only bleeding presentation, spontaneous bruising doesn’t occur until platelet count is under 30,000
. Fatigue common
. Diagnosis of exclusion
. Secondary causes: leukemia, meds, lupus, cirrhosis, HIV, hep C

Question 26

ITP in children

Answer 26

. Acute
. Follow after viral vaccines
. Resolves w/in a few weeks w/o treatment

Question 27

ITP in adults

Answer 27

. Chronic 
. No prodrome
. Idiopathic 
. Affects more women 
. Requires treatment

Question 28

Disseminated intravascular coagulation

Answer 28

. Always has underlying etiology
. Cause must be identified to treat coagulopathy triggering factor damages vessels
. Uncontrolled activation of coag cascade where many clots develop throughout vasculature
. Inc. clotting depletes platelets and clotting factors creating excessive bleeding
. May cause tissue ischemia from occlusive thrombi AND bleeding from consumption of platelets and clotting factors
. Caused from sepsis, trauma, burns, obstetric complications, and cancer
. Bleeding in multiple sites, petechia/ecchymosis, gangrene

Question 29

Drug induced thrombocytopenia

Answer 29

. Severe mucocutaneous bleeding 7-14 days after exposure
. Discontinuation of meds leads to resolution in 7-10 days
. Recovery kinetics depends on rate of drug clearance

Question 30

Heparin-induced thrombocytopenia

Answer 30

. Immunologically mediated adverse reaction causing formation of IgG antibodies to heparin-platelet factor 4 complexes
. Causes inappropriate activation of platelets, thrombocytopenia, and pro thrombi state
. Thrombosis in both arterial and venous systems occur in up to 50% of cases
. Decline in baseline platelet count of 50% or more
. Onset occurs w/in 5 to 14 days or exposure to heparin

Question 31

Aspirin

Answer 31

. Irreversibly binds to platelets
. Inhibits COX and TBA2 production
. Produces inhibitory effect of platelet aggregation

Question 32

NSAIDS

Answer 32

. Inhibits platelet COX and TXA2

. Reversible bind to platelets for limited time

Question 33

Plavix

Answer 33

. Platelet receptor inhibitor

. Inhibits platelet adhesion and aggregation

Question 34

Alcohol effect on platelets

Answer 34

. Dec. TXA2 release

Question 35

Hemophilia

Answer 35

A: VIII issue
. B: IX issue
. Severity inversely proportional to factor levels
. Mild: spontaneous bleeding rare but can occur w/ significant surgery or trauma
. Severe: presents in infants w/ spontaneous bleeding into joints
. Female carries asymptomatic

Question 36

Hemophilia C

Answer 36

. Factor XI deficiency
. Autosomal recessive
. Jew problem
. Most mild form of bleeding

Question 37

Factor XIII deficiency

Answer 37

. Involved w/ process of cross linking fibrin
. Delayedbleeding occurs hours to days after hemostatic challenge
. Spontaneous intracranial hemorrhage and recurrent pregnancy loss are indicators

Question 38

Acquired antibodies to factor VIII

Answer 38

. Acquired hemophilia A
. Spontaneous antibodies to factor VII in adults w/o prior history
. High risk: lymph malignancy, CT disease, post party’s, or post surgery
. Clinical presentation: soft tissue ecchymosis, hematoma, mucosal bleeding
. Leads to severe life threatening bleeding

Question 39

Liver disease effect on bleeding

Answer 39

.dec. synthesis of clotting factors
. Splenomegaly
. Thrombopoietin controls circulating platelets by stimulating marrow to produce megakaryocytes and is impaired
. Complication from cirrhosis may be esophageal varices

Question 40

Vit, K deficiency

Answer 40

. Dec. synthesis of factors II, VII, IX,

. Occurs as result of dietary deficiency, malabsorption, dec. production by intestinal bacteria

Question 41

Warfarin (Coumadin)

Answer 41

. Vit. K antagonist

. Inhibits vit. K dependent carboxylase important for coag factors II, VII, IX, and X