Bleeding Stigmata

Can be platelets or coagulation cascade.

 

Bruises bigger than a size of a toonie.

Locations not likely to be trauma.

Nosebleeds (epistaxis): duration, oozing from both nostrils.

Hematemesis

 

Petechiae can be normal on chest and neck following vigorous coughing, vomiting, etc.

It is, however, a red flag, suggestive of platelet dysfunction.

 

 

Assessing Bleeding

  • prolonged INR
  • low platelets
  • prolonged PTT
  • normal values

Prolonged INR

 

50:50 correction suggests factor deficiency.

VII deficiency - genetic

 

X, IX, VII, II

  • warfarin
  • vitamin K deficiency

Low Platelets

 

Increased INR, PTT

 

Suggests DIC

 

Prolonged PTT

 

50:50 correctible

VIII, IX

sex-linked, hemophilia A and B

PTT 60-80s

 

 

XI, XII

autosomal dominant

 

VWB

normal platelet numbers, but increased PFA (platelet function analysis)

 

50:50 - non-correctible

inhibitory antibody

  • someone with hemophilia who has been getting VIII replacement
  • elderly (cause unknown; difficult to treat)
  • lymphoma
  • pregnancy (transient)

Treatment

  • emergent: exogenous activated F VII
  • imunosuppressants (cytoxan, prednisone)
  • IVi

 

heparin (commonly from line flushing)

  • identify with thrombin time (TT) or hepabsorb

APLA

 

 

Normal Values

 

Normal platelets, INR, PTT

Suggests dysfunctional platelets

  • ASA, clopidogrel
  • uremia (prevents aggregation)

PFA (platelet function analysis) will show dysregulation

 

  • history
  • physical exam

History

Physical Exam