Diagnosis and Management of Bleeding and Clot Disorders Flashcards
You have a patient who comes in complaing that they always bleed when they brush their teeth. You ask about any other odd bleeding and she says that she gets nose bleeds, but it isn’t a big deal because she has always had them. What do you suspect?
Platelet disorder, need more info such as PT, PTT
What does VWf bind to and what happens if there is a deficiency?
- Binds to GpIb on platelets, VWf is on the epithelium
- It allows for adhesion
- If there is a deficiency it disrupts platelet binding to the epithelium
6 yo male with oral bleeding after dentist. Hx of easy bruising with minor trauma, prior ED visit for pain and swollen knee.
PE normal vital and bruises on extremities and abdomen.
CBC: normal
PT: 13 (normal)
PTT: 89 (abnormal)
Bleeding time normal
Factor VIII: 3% normal activity
Factor IX: 98% normal
What could be going on?
- Hemophilia A
- Factor 8 has 3% of normal activity
- Factor IX has 98% normal so it is not Hem. B
How do you manage and treat Hemophilia A?
- Prevent bleeding
- Tx is to make severe bleeding mild by using Emicizumab, it is a recombinant FVIII which binds FIXa and X
- downside is its very expensive
32 yo heavy vaginal bleeding, nose bleeds, fatigue, no PMH of bleeding/bruising until now. Mom has RA, dad has Htn, sister SLE.
Vitals: BP 98/62, pulse 104
PE: conjunctival pallor, small ecchymoses on legs arms, no lacerations and vaginal bleeding
CBC:
- Hgb: 10 (low)
- Hct: 32.9 (low)
- Normal WBC and platelets
- Bleeding time normal at 4 min
- PT: normal
- PTT high
Mixing study for PTT did NOT correct, what does this indicate?
- Her plasma has an inhibitorhy antibody
- With a deficiency the factor activity should fully correct in a mixing study
- However with antibodies, they will bind to the factors in the normal plasma and incactivate those as well resulting in no correction
32 yo heavy vaginal bleeding, nose bleeds, fatigue, no PMH of bleeding/bruising until now. Mom has RA, dad has Htn, sister SLE.
Vitals: BP 98/62, pulse 104
PE: conjunctival pallor, small ecchymoses on legs arms, no lacerations and vaginal bleeding
CBC:
- Hgb: 10 (low)
- Hct: 32.9 (low)
- Normal WBC and platelets
- Bleeding time normal at 4 min
- PT: normal
- PTT high
Mixing study does not correct and we come to a diagnosis of Acquired Hemophilia A. What does this mean? (What factor is the isssue)
- The patient has a problem with Factor VIII, and because the mixing study did not correct we know that she also has Ab’s to this factor
- She would be positive for Factor VIII inhibitor
How do you treat acquired Hemophilia A?
- Fluid support
- Address the inhibition with immunosuppression
Who do you see Factor VIII inhibitor (accquired Hemophilia A) in typically?
- Older adults
- Postpartum women
- Those with Autoimmune disease
- Malignancy
Describe PT, PTT, Bleeding time and platelets for:
- VWD
- Hemophilia A and B
- ITP
- DIC
- Warfarin
- Heparin
- Glanzmann
- Bernard Soulier
Describe Virchow’s Triad.
- Venous stasis:
- intra operative period, post operative, traveling long distance
- Endothelial injury:
- Trauma, implants, catheters
- Hypercoagulability:
- Genetic mutations, nephrotic syndrome, hyper viscosity due to malignanacy, AI, smoking, birth control
Risk factors for VTE?
- Prior PE or DVT
- Malignancy
- Recent fracture surgery or hospitilization
- Immoblization
- Obesity
- >65 yo
What labs/radiography would you use to diagnose a thromboembolism?
- D dimer
- degradation of cross linked fibrin
- Ultrasound for DVT
- CT angiogram for PE
If a D dimer test is negative, should you still do more studies to rule out thromboembolism?
No, it has very high negative predictive value
Describe the comression US for DVT?
- Veins are normally comressible, so if you can’t comress the vein it could be due to a space occupying clot
36 yo female with abdominal pain that started 4 hrs ago. It is getting increasingly worse and she has vomitted twice in the ED since arrival.
- PMH: spontaneous miscarriage 12 years ago
- Meds: MVI and oral contraceptive
- FHx: mother died from a stroke at 45 yo
PE: abdomen pain, occult blood in stool
Labs: elevated WBC 15.4 (normal 3.8-11), increased neutrophils and left shift.
Radiography shows dilated loops of small bowel, Ileus. Upon exploration she is found to have bowel infarction due to mesenteric vein thrombosis.
Is this more likely to be congenital or acquired?
She is found to have Protein C&S deficiency. Describe what this indicates?
- acquired due to her family history, although oral contraceptives can cause exacerbate this
- Protein C and S block sites on factors VII and V to stop the clotting cascade, and our patient is lacking these. This results in excess clotting resulting in thrombophilia
