Bleeding tendency

hematology

1. Approach to bleeding tendency Hamad E mad H. D huhayr

2. Content Overview approach to bleeding tendency Taking history Physical examination Laboratory references

3. Vascular contraction Local myogenic spasm Local autacoid factors from traumatized tissue and blood platelets Nervous reflexes

4. Red blood cell Platelet

5. Red blood cell Platelet

6. Red blood cell Platelet Von Willebrand factor

7. Red blood cell Platelet Von Willebrand factor

8. Red blood cell Platelet Von Willebrand factor

9. Red blood cell Platelet Von Willebrand factor

10. Red blood cell Platelet Von Willebrand factor

11. Red blood cell Platelet Von Willebrand factor

12. Red blood cell Platelet Von Willebrand factor

13. Red blood cell Platelet Von Willebrand factor

14. Red blood cell Platelet Von Willebrand factor

15. Red blood cell Platelet Von Willebrand factor Fibrin polymer

16. Red blood cell Platelet Von Willebrand factor Fibrin polymer

17. Red blood cell Platelet Von Willebrand factor Fibrin polymer

18. Evaluation of the patient History Physical Examination Laboratory Evaluation

19. History taking Identify if the bleeding problem is due to Local vs. Systemic defect Location: single vs. Multiple sites Severity: spontaneous? Appropriate to trauma? Hereditary vs. Acquired disorder Onset Family history Underlying disease Medication Primary vs. Secondary hemostatic disoder

20. Primary Hemostatic defect Secondary Hemostatic defect

21. Physical Examination Current hemorrhage Nature and extent Intercurrent illnesses Liver disease Petechiae / ecchymoses

22. Laboratory Assessment Guided by history Screening tests PT aPTT platelet count fibrinogen thrombin time

23. Assessment of Primary Hemostasis Platelet Complete blood count (CBC) Bleeding time/ PFA-100 Platelet aggregation study Blood vessel Bleeding time von Willebrand factor ( vWF ) Bleeding time vWF Antigen, vWF : RCO, vWF multimer , FVIII

24. 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

25. Etiology of Thrombocytopenia Decreased Production Hypoproliferation Ineffective Thrombopoiesis Aplastic Anemia, Amegakaryocytic thrombocytopenia, infection, toxins, drugs Infiltrative marrow disease, TAR Megaloblastic anemia Increased Destruction Immune Non-immune Alloimmune, Autoimmune: ITP, SLE DIC, TTP, HUS Others Splenic sequestration Dilutional Hypersplenism Massive blood transfusion

26. Bleeding Time

27. Bleeding Time: Interpretation Normal value* : 1-9 min Prolonged bleeding time: Thrombocytopenia/ anemia ( hct < 20%) Hereditary platelet dysfunction Von willebrand disease Severe hypofibrinogenemia Blood vessels disorders Uremia Myeloproliferative disorders Medication: aspirin, nsaids,other antiplatelet drugs

28. Platelet Aggregation Study

29. Assessment of Secondary Hemostasis Screening tests: PT aPTT Mixing study Additional Tests Fibrinogen Thrombin Time Reptilase time Coagulation factor assays D-dimer Fibrin Degradation Product Euglobulin lysis time

30. Prothrombin Time (PT) PT : test extrinsic and common pathway

31. Activated Partial Thromboplastin Time (aPTT) aPTT : test intrinsic and common pathway

32. 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%

33. Interpretation of Abnormal Coagulogram Isolated prolonged PT Isolated prolonaged aPTT Prolonged PT and aPTT

34. 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

35. 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 XII Factor IX Factor IX HMWK HMWK Factor XI Factor XI Prekallekrein Prekallekrein Heparin Lupus anticoagulant

36. Acquired FVIII inhibitor

37. 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

38. Summary History & Physical Examination Laboratory tests screening tests specific diagnostic tests Diagnosis-specific therapy Factor replacement Drugs

39. Refferences Kumar Cecil Website