APPROACH TO BLEEDING TENDENCY

Hamad Emad H. Dhuhayr

CONTENT

• Overview

• approach to bleeding tendency

1. Taking history

2. Physical examination

3. Laboratory

• references

VASCULAR CONTRACTION

1. Local myogenic spasm

2. Local autacoid factors from traumatized tissue and blood platelets

3. Nervous reflexes

Red blood cellPlatelet

Red blood cellPlatelet

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factor

Red blood cellPlatelet

Von Willebrand factorFibrin polymer

Red blood cellPlatelet

Von Willebrand factorFibrin polymer

Red blood cellPlatelet

Von Willebrand factorFibrin polymer

EVALUATION OF THE PATIENT•HISTORY

•PHYSICAL EXAMINATION

•LABORATORY EVALUATION

History taking

Identify if the bleeding problem is due toLocal vs. Systemic defect

Location: single vs. Multiple sitesSeverity: spontaneous? Appropriate to trauma?

Hereditary vs. Acquired disorderOnsetFamily historyUnderlying diseaseMedication

Primary vs. Secondary hemostatic disoder

Primary Hemostatic defect

Secondary Hemostatic defect

PHYSICAL EXAMINATION• Current hemorrhage

• Nature and extent

• Intercurrent illnesses

• Liver disease

• Petechiae/ecchymoses

LABORATORY ASSESSMENT• GUIDED BY HISTORY

• SCREENING TESTS

• PT

• APTT

• PLATELET COUNT

• FIBRINOGEN

• THROMBIN TIME

ASSESSMENT OF PRIMARY HEMOSTASISPLATELET

COMPLETE BLOOD COUNT (CBC)BLEEDING TIME/ PFA-100PLATELET AGGREGATION STUDY

BLOOD VESSELBLEEDING TIME

VON WILLEBRAND FACTOR (VWF)BLEEDING TIMEVWF ANTIGEN, VWF: RCO, VWF MULTIMER, FVIII

COMPLETE BLOOD COUNT (CBC)

PLATELET NUMBER

NORMAL PLATELET COUNT: 150,000 –400,000/UL

> 100,000/UL BLEEDING UNLIKELY

< 20,000/UL ↑ RISK FOR SPONTANEOUS

BLEEDING

MUST EXCLUDE PSEUDOTHROMBOCYTOPENIA

ASSESS FOR PLATELET MORPHOLOGY

Etiology of Thrombocytopenia

Decreased Production

• Hypoproliferation

• Ineffective Thrombopoiesis

• Aplastic Anemia, Amegakaryocytic

thrombocytopenia, infection, toxins, drugs

Infiltrative marrow disease, TAR

• Megaloblastic anemiaIncreased Destruction

• Immune

• Non-immune

• Alloimmune, Autoimmune: ITP, SLE

• DIC, TTP, HUS

Others

• Splenic sequestration

• Dilutional

• Hypersplenism

• Massive blood transfusion

BLEEDING TIME

BLEEDING TIME: INTERPRETATION

Normal value* : 1-9 minProlonged bleeding time:

Thrombocytopenia/ anemia (hct < 20%)Hereditary platelet dysfunctionVon willebrand diseaseSevere hypofibrinogenemiaBlood vessels disordersUremiaMyeloproliferative disordersMedication: aspirin, nsaids,other antiplatelet drugs

PLATELET AGGREGATION STUDY

ASSESSMENT OF SECONDARY HEMOSTASIS SCREENING TESTS:

PT

APTT

MIXING STUDY

ADDITIONAL TESTSFIBRINOGEN

THROMBIN TIME

REPTILASE TIME

COAGULATION FACTOR ASSAYS

D-DIMER

FIBRIN DEGRADATION PRODUCT

EUGLOBULIN LYSIS TIME

PROTHROMBIN TIME (PT)

PT : test extrinsic and common pathway

ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT)

aPTT : test intrinsic and common pathway

MIXING STUDY

+

0% 100%

50%

<35%

Correctable

Normal coagulation

time

Uncorrectable

prolonged coagulation

time

Deficiency

Inhibitor

Prolonged PT or aPTT occurs when coagulation factor < 35-40%

INTERPRETATION OF ABNORMAL COAGULOGRAM

ISOLATED PROLONGED PT

ISOLATED PROLONAGED APTT

PROLONGED PT AND APTT

Isolated prolonged PT

Mixing study

Correctable Uncorrectable Deficiency Inhibitor

Hereditary: FVII FVII (rare) Lupus anticoagulant Acquired: Early liver impairment

Vitamin K antagonist Vitamin K deficiency

Isolated prolonged aPTT

Bleeding No bleeding

Mixing study Mixing study

Correctable Uncorrectable Correctable Uncorrectable

Deficiency Inhibitor Deficiency Inhibitor

Factor VIII /vWD Factor VIII Factor XII Factor XIIFactor IX Factor IX HMWK HMWKFactor XI Factor XI Prekallekrein Prekallekrein Heparin Lupus anticoagulant

Acquired FVIII inhibitor

Prolonged aPTT and PT

Mixing study

Correctable Uncorrectable

- FII,FV or FX deficiency - FII, V, or X inhibitor - FV and VIII deficiency - Lupus anticoagulant - Liver disease - LAC + Factor inhibitor - Vitamin K antagonist - Vitamin K deficiency - DIC

SUMMARY

• HISTORY & PHYSICAL EXAMINATION

• LABORATORY TESTS

• SCREENING TESTS

• SPECIFIC DIAGNOSTIC TESTS

• DIAGNOSIS-SPECIFIC THERAPY

• FACTOR REPLACEMENT

• DRUGS

REFFERENCES

• KUMAR

• CECIL

• WEBSITE