L40 Clinical Evaluation of the Bleeding Patient Flashcards
What are the 3 categories of bleeding disorders?
- Vascular
- Platelet
- Clotting Factor
What are the 2 categories of platelet disorder?
- Quantitative
2. Qualitative
What are the 3 categories of clotting factor disorder?
- Deficiency
- Inhibitor
- Functional defect
What is on the differential diagnosis for quantitative platelet disorders (primarily thrombocytopenia)?
- Idiopathic Thrombocytopenic Purpura (ITP)
- Drug-induced thrombocytopenia
- Hypersplenism
- Marrow infiltration by neoplasia
- Viral infections (HIV, EBV, Rubella)
- DIC
- TTP-HUS
- Autoimmune condition such as lupus
- Gestational thrombocytopenia
What is on the differential for qualitative platelet disorders (inherited and acquired)?
Inherited:
- Von Willebrand’s Disease
- Glanzzman Thrombasthenia
- Bernard-Soulier Syndrome
Acquired:
- Drugs
- Chronic renal failure
What is on the differential for clotting factor abnormalities (inherited and acquired)?
Inherited:
- Hemophilia A (factor 8 deficiency)
- Hemophilia B (factor 9 deficiency)
- Other factor deficiencies (less common)
Acquired:
- Vitamin K deficiency
- Factor inhibitors
- Failure of synthetic function of the liver
- Drugs
- DIC
What are important aspects of a patient history when investigating a possible bleeding disorder?
- Surgeries, tooth extraction, childbirth
- Bleeding that required surgical intervention, transfusion, or replacement history
- Positive family history
- Circumcision in boys
- Menorrhagia in women
- Medications (warfarin, heparin, aspirin, plavix, etc.)
- Viral illness, malnutrition, liver disease, malignancy
What should you look for on a physical exam when there is concern for a bleeding disorder?
- Epistaxis, bruising, petechiae, hematomas
- Oral cavity bleeding
- Hematemesis, hematochezia, melena
- Hemarthrosis
- CNS bleeding
- Lymphadenopathy
- Spleno/hepatomegaly
What are some clues that a quantitative platelet disorder is occurring?
Mucosal bleeding, bruising, petechiae, or purpura
What are some clues that a qualitative platelet disorder is occurring?
Patient with a lifelong history of bleeding despite negative laboratory work-up
What are some clues that a factor deficiency is occurring?
Joint or soft-tissue bleeding; family history of bleeding in men (skips generations)
What are some clues that a factor inhibitor issue is occurring?
Similar presentation to hemophilia, but no patient or family history of bleeding
What are some clues that DIC is occurring?
Bleeding from multiple sites, prolonged PT and PTT
What are some clues that a Vitamin K Deficiency is occurring?
Malabsorption, poor diet, drugs that bind vitamin K
What does immediate (vs. delayed) bleeding indicate?
Platelet problem
What does delayed (vs. immediate) bleeding indicate?
Clotting problem
What might a prolonged PT/INR (and a normal PTT) indicate?
- Warfarin
- Liver disease
- Factor 7 deficiency
What might a prolonged PTT (and a normal PT/INR) indicate?
- Heparin
- Factor 8, 9, 11, 12 deficiency
- Lupus anticoagulant
What might a prolonged PT and PTT indicate?
- High dose warfarin or heparin
- Liver disease
- DIC
- Vitamin K deficiency
- Prothrombin, fibrinogen, factor 5, 10, or combined factor deficiency
What are the two basic reasons for an elevated PT or PTT?
- Deficiency of a clotting factor
2. Inhibition of a clotting factor
How do you differentiate between a deficiency or inhibition of a clotting factor?
Mixing study
What is done in a mixing study?
Take 1 part normal plasma and 1 part patient plasma, mix them, and repeat the APTT; correction indicates a deficiency of clotting factor. No correction indicates an inhibitor.
What test is done to confirm a deficiency of clotting factor?
Factor assay
What test is done to confirm an inhibitor of clotting factor?
Lupus anticoagulant testing
95-97% of all inherited coagulation defects involve which disorders?
X-lined inherited coagulation disorders (hemophilia A and B) and von Willebrand disease
What is the limitation to treating with fresh frozen plasma in factor 7 deficiency?
Factor 7 has a very short half-life, so the effect is ~4-6 hours
What information does a CBC provide?
- Platelet quantity
- Involvement of other cell lines
- Platelet appearance
- Evidence of a systemic disorder
What information do PT and aPTT provide?
- Coagulation system abnormalities
- Picks up both qualitative and quantitative defects but does not differentiate between them
- Sometimes differentiate which clotting factor is the culprit
What information does a bleeding time test provide?
- Defect in platelet plug formation/platelet function
If there is a defect or lack of vWF, what else will be affected?
Factor 8 (carried on vWF)
Describe the platelet count, bleeding time, and other features of ITP.
- Decreased platelets
- Increased bleeding time
- Anti-2b3a antibodies, leading to consumption of platelets
Describe the bleeding time and other features of BS syndrome.
- Increased bleeding time
2. Defect in platelet plug formation; decreased 1b leads to impaired platelet-vWF adhesion
Describe the bleeding time and other features of Glanzmann Thrombasthenia.
- Increased bleeding time
2. Defect in platelet plug formation; decreased 2b3a leads to impaired platelet-platelet aggregation
Describe the bleeding time, PT, PTT, and other features of VW disease.
- Increased bleeding time
- Normal PT
- Increased PTT
- Intrinsic pathway coagulation defect; decreased vWF increases PTT and impairs platelet-vWF adhesion
Describe the platelet count, bleeding time, PT, PTT, and other features of DIC.
- Decreased platelet count
- Increased bleeding time
- Increased PT
- Increased PTT
- Widespread activation of clotting leads to a deficiency in clotting factors; increased fibrin degradation products (D-dimer), decreased fibrinogen
