Haematology Flashcards
What factors of a prosthetic valve replacement affect the risk of anticoagulation referral?
What would the daily thrombosis risk be?
valve location - mitral more risk than aortic
valve material - metal more than prosthetic
risk is less than 1%
What drugs are used to reverse warfarin?
Vit k 10mg IV
Prothrombinex 50u/kg iv
FFP 2 units
Name 6 lab targets post massive transfusion
- PH >7.2
- Lactate <4
- Ca >1.1
- Platelets over 50
- INR less than 1.5
- fibrinogen over 1
- aptt less than 1.5 normal
- base excess less than - 6
In an acute bleeder what are the 5 steps of management
Resus
Reversal
Analgesia - fentanyl
Specific - IR
Disposition - ICU/HDU for monitoring
What are the findings in this CT of bleeder
left sided abdominal wall haematoma
arterial blush - active bleeding
Swirl sign – hypodensity – suggesting active bleeding
NB negatives
No haemoperitoneum / pneumoperitoneum
in a child with petichial rash
diagnosis?
Why
iron deficient anaemia secondary to menorrhagia
low HB, low MCV, low haematocrit
blood transfusion - What is happening?
4 complications
haemolytic transfusion reaction - occurs in first 24 hours as immune response to blood
Complications
* DIC
* renal failure
* ARDS
* pulmonary oedema
* Death
what are the immediate, short term and long term management priorities with haemolytic transfusion reaction?
immediate
* stop tranfusion
* treat shock
* oxygen
short term
* investigate cause eg culture the bllod
* clarify details with staff
* open disclosure
- long term
- ongoing disclosure
- M and M
- education
list five differentials of symptomatic anaemia with FBC investigaiton plus another key investigation
what are the indicaitons for a blood transfusion?
symptomatic
hb under 70
co morbiditis eg CCF, liver failure
list four early and four late complications of blood transfusion
Early
1. acute haemolytic reaction
2. actue febrile non haemolytic reaction
3. sepsis
4. anaphylaxis
Late
1. blood borne viruses eghiv
2. alloimmunisation
3. post tranfusion thrombocytopenia
4. iron overload
what are alternatives to blood transfusion
oral iron
iv iron
EPO
what are the significant findings?
diagnosis in someone with long term nsaid use?
severe microcytic anaemia
low hb, red cell count,packed cell volume
Diagnosis
UGIB
finding?
pancytopenia
what are three central and three peripheral causes of pancytopenia?
Central (marrow affected)
1. aplastic anaemia
2. myelofibrosis
3. leukemia/lymphoma
4. chemo induced
5. TB
Peripheral
1. sepsis
2. hyposplenism
3. autoimmune
what blood products can be used without confirming compatibility?
- O neg
- platelets
- FFP
- prothrombinex
- cryoprecipitate
what are the descriminating features of each transfusion reaction?
differentials?
list differentials to help diagnosis
management
- ITP - blood film for platelet bound antibodies - steroids
- Thrombotic thromocytopenic purpura - blood film for schistocytes - plasma exchange and steroids
- Sepsis - coags for DIC - abx and souce control
- haematological malignancy - bone marrow biopsy - oncology referral
- bone marrow suppresion eg drugs - bone marrow aspirate - treat or cease cause
differentials for microcytic anaemia
- iron deficient anaemia from GI GU loss
- IDA from poor diet
- haemolysis
- haemaglobinopathy
- bone marrow malgnancy or infiltration
- megaloblastic anaemia from b12/folate deficiency
- anaemia of chronic disease
main features
What investigations and why?
petichaie and purpura both legs
bruising
ix:
Coag profile - bleeding or DIC
FBC - ?low platelets
Renal function - ?MAHA or TTP
CT head - if trauma possible in hx
septic screen if febrile
low platelets - diagnosis?
immune thrombocytopenic purpura
if someone has ITP and ongoign bleeding with low GCS what is the management?
IV igs
IV methylpred
IV platelets
LP under 50
CVC under 20
asymptomatic under 10
what are the features of thrombotic thrombocytopenic purpura?
What are the treatment options?
- Fever
- thrombocytopenia
- renal impairtment
- CNS changes - headache, altered menta state
- microangiopathic haemolytic anaemia
Treatment
1. plasmapheresis
2. corticosteroids
3. splenectomy
what are the risk factors for a fatal anaphylaxis reaction?
- asthma
- atopic disease
- delay or no adrenaline
- upright posture during shock
- cardiorespiratory disease in general
- misdiagnosis of condtion
- erratic behaviour around allergens
what skin manifestations are consistent with anaphylaxis?
- itch
- erythma
- urticaria
- angiodema
- pallor
What are the steps in using an epipen?
- store at room temp
- use the epipen as soon as you recongnise youre having reaction
- flip open the carrier tube and grip in hand with needle pointing down
- remove safey cap on the end and push against upper outer thigh
- push in until click and hold for 3 seconds
- remove and massage area for 10 seconds
what are the normal side effects of im adrenaline?
serious side effects
Normal:
* nausea
* tremor
* anxiety
* palpitations
* headache
Serious:
* hypertensive crisis
* MI
* VT
* ICH
* APO
* gangrene
describe two abnormalities?
Interpretation
tongue oedema with protrusion
peri orbital erythema
pallor
likely anaphylaxis
what are the signs of impeding airway obstruction in anaphylaxis
stridor
hypoxia
increased WOB
reduced GCS (fatigue)
what are the treatment steps for anaphylaxis?
- IV fluid to mainrain BP over 90
- Stat IM adrenaline 500mcg repeating after 5 mins up to 3 times
- IV adrenaline infision at 60ml/hr (5-10mcg/min)
aiming for reduction in sx
what does a positive coombs test indicate?
immune mediated
what bloods suggest haemolytic anaemis
Bilirubin – increased indirect
* Haptoglobins- decreased
* LDH – elevated
* Coags
* U/A and micro – casts = renal, haematuria, urinary haemosiderin (severe haemolysis)
* Blood film – polychromasia – increased RBC production, bite cells – splenic removal hb,
Heinz bodies, rule out malaria
* G6PD level – should be taken during well stages so no mark for this
what can cause G6PD
what is the treatment
- Drugs – antimalarials, sulphonamides, cipro, aspirin - trimethoprim
- Infections – multiple –
- Napthalene blue (moth balls)
- Fava beans
- Ketoacidosis
Treatment
IV fluid
oral folate
define massive transfusion
as replacement of >1 blood volume in 24 hours or >50% of blood volume in 4 hours
OR
> 10 u in 24 hours, or persistent losses of >150ml/hour
what are the potential complications of a massive transfusion
- volume overload
- hypothermia
- dilutional coagulopathy
- TRALI
- hyperkalemia
- disease transmission
DOAC and ICH
What treatments may you use and why?
What may affect decision?
- PRBC and platelets - ongoing blood loss
- TXA - low cost and low ris
- Desmopressin - low cost and risk
- idarucizumab - only works for dabigatran
- Not FFP in DOACS
- haemodialysis in dabigatran
affecting decision
* time of ingestion
* renal and liver function
what is this
contre-coup injury
bleeding occuring on opposite side of brain where direct trauma was
right fronto-tempero cerebral contusion
small SDH
tissue haematoma
haemophilia A and bleeding - what can you give
factor 8a
when and how do you reverse warfarin in actve bleeding
INR over 2
how:
IV vit k 10mg
prothrombinix 35-50u/kg
