An approach to a bleeding patient clinically

1. Approach to Bleeding
Patient
Haematology Department – Dr M. Phetshula

2. Objectives
 Understand the basics of hemostasis
 Platelets
 Clotting factors
 Blood Vessel
 Clinical features of a bleeding disorder
 Laboratory evaluation
 Common bleeding disorders
• Thrombocytopaenia
• Hemophilia

3. Haemostasis
•Primary Hemostasis
– Involves platelets, vWF, and vessel wall
– Goal is platelet plug formation at site of injury
– Platelet plug stops bleeding, but is unstable
• Secondary Hemostasis
– Involves the clotting factors
– Goal is stabilization of platelet plug
– Leads to fibrin clot formation

4. The Platelet plug

6. Evaluation of bleeding disorders
 History Taking
 Physical examination
 Screening clinical laboratory tests

7. History
 Observation of excessive bleeding following a surgical procedure
 Bleeding problems in relatives
 Bleeding problems following operations and tooth extractions, trauma, heavy
menses, post partum haemorrhage
 Use of drugs for prevention of coagulation or pain
 Spontaneous bleeding from nose, mouth etc..

8. Physical examination
 Jaundice
 Petechiae: < 0.2 cm
 Purpura: 0.2 cm-1 cm
 Eccymoses > 1 cm
 Spider angioma
 Oral ulcer
 Hyperplasia of gingiva
 Haemarthrosis
 Mucosal bleeding

9. Screening laboratory tests
 First line testing
 –FBC
 –Peripheral smear
 –Prothrombin time (PT)
 –Partial thromboplastin time (PTT)
 –Fibrinogen
 –Thrombin time
 –von Willebrand panel
•Factor 8 activity, vWF antigen, vWF activity
 –PFA-100

10.  Subsequent testing-repeat all abnormal tests
–Factor XIII test
–PTT abnormal
•PTT mixing study
•Factor 8, 9, 11, 12 levels
•Lupus anticoagulant, Anti phospholipid testing
–PT abnormal
•PT mixing study
•Factor 7
•Protein C and S activity
–vWF panel abnormal
•Repeat testing
•vWF multimers

11. PT PTT Plt DDx Follow-up tests
N ↑ N PTT inhibitor PTT mixing study, lupus anticoagulant, cardiolipin Ab’s
von Willebrand
disease
von Willebrand panel including multimers
Hemophilia A or B Factor VIII and IX activity
Factor XI Deficiency Factor XI activity
Heparin contamination Thrombin time
PT PTT Plt DDX Follow-up tests
N N N von Willebrand disease PFA-100
von Willebrand panel, including multimers
Platelet function disorder Platelet aggregation studies
Factor XIII deficiency Ureaclot lysis test

12. PT PT Plt DDX Follow-up Tests
↑ N N PT inhibitor
Vitamin K deficiency Factors II, VII, IX, X, protein C and proteinS
Warfarin
Factor VII deficiency Factor VII activity

13. PT PTT Plt DDX Follow-up Tests
↑ ↑ Circulating inhibitor Mixing studies, lupus anti coagulant,cardiolipin Ab’s
Liver dysfunction Liver enzymes, thrombintime, reptilase time
Vitamin K deficiency Factors II, VII, IX, X,protein C and protein S
FactorII, V, and X deficiency Factor activity assay
DIC DIC screen, assess and treat for underlying cause

14. Physiology of Lab Parameters
Platelet count
 Normal (140,000 to 400,000/mm3)
 Thrombocytopenia : <140,000/mm3
 Clinical bleeding problem : <50,000/mm3
 Spontaneous bleeding with life threatening :<20,000/mm3
APTT
 The APTT is a test of the integrity of the intrinsic and common pathways of coagulation.
 The in vitro clotting time is measured after addition to plasma of calcium and the APTT reagent, which
contains phospholipid (a platelet substitute, also called ‘partial thromboplastin’ as it lacks tissue factor),
and an intrinsic pathway activator e.g. kaolin.
 The APTT should be designed to detect bleeding disorders due to deficiencies of factors VIII, IX, and XI
and inhibitors of the intrinsic and common pathway factors (including lupus anticoagulant and therapeutic
anticoagulants).
 Inevitably, it also detects deficiency of factor XII.

15. Activated PTT (aPTT)
 Activated by contact activator (kaolin)
 Tests intrinsic and common pathway
 Normal ( 25-35 sec )
 Heparin therapy- PTT in 50-65 sec range by promote AT III
PT
 The PT assesses the integrity of the extrinsic and common pathways.
 The in vitro clotting time is measured after addition of the PT reagent, which
contains thromboplastin (phospholipids with tissue factor) and calcium to citrated
plasma.
 PT prolongation should detect important deficiencies (or rarely inhibitors) of
factors II, V, VII and X.
 Its main use is for anticoagulant monitoring and detection of acquired bleeding
disorders (especially disseminated intravascular coagulation, liver disease and
vitamin K deficiency).

16. PT (Prothrombin Time)
 Activated by tissue thromboplastin, tests extrinsic ( factor VII ) and common ( I,II,V,X ) pathways
 Normall ( 11-15 sec )
 Coumarin therapy- PT at 1.5 to 2.5 time
 International normalized ratio (INR): the ratio of a patient's prothrombin time to a normal (control)
sample, raised to the power of the ISI value for the analytical system used.
TT (Thrombin Time)
 Activated by thrombin
 Tests ability to form initial clot from fibrinogen
 Normall ( 9 to 13 seconds )
Skin bleeding time
 This is the only in vivo hemostasis test available..
 It is used to test for defects of platelet-vessel wall interaction and should detect inherited or
acquired disorders of platelet function, von Willebrand disease (VWD) and abnormalities of vessel
wall integrity

17. Thrombocytopaenia
 There are 3 major mechanisms of thrombocytopenia:
 impaired production, increased destruction and abnormal sequestration or dilution.
 Impaired platelet production can be due to congenital disorders (amegakaryocytic
thrombocytopenia, May-Hegglin anomaly), viral infection, alcohol, B12 or folate
deficiency, bone marrow infiltration (leukemia, myelofibrosis, metastatic cancer),
chemotherapy or radiation, paroxysmal nocturnal haemoglobinuria, or
myelodysplasia.
 The peripheral smear may provide clues to the diagnosis. E.g. a leukoerythroblastic
smear (teardrop cells, nucleated RBCs, and early myeloid precursors) suggests an
infiltrative process, whereas oval macrocytes and hypersegmented neutrophils
suggest a B12 or folate deficiency.
 Disorders associated with increased platelet destruction include immune
thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura,
disseminated intravascular coagulation (DIC), infection, sepsis, antiphospholipid
antibody syndrome, drugs, heparin-induced thrombocytopenia (HIT), and
cardiopulmonary bypass.

18. ITP is characterized by autoantibody-mediated platelet destruction, with the majority of platelet autoantibodies
directed against platelet GpIIb/IIIa or GpIb/IX complexes on the platelet surface.
 ITP is a diagnosis of exclusion, and tests for antiplatelet antibodies are not useful for diagnosis or for
guiding therapy.
Thrombotic thrombocytopenic purpura is associated with thrombocytopenia, microangiopathic haemolytic
anemia, and often fever or renal or neurologic abnormalities. The pathophysiology involves both endothelial
damage with release of ultralarge multimers of von Willebrand factor (vWF) and a deficiency of a plasma vWF-
cleaving protease.
 The diagnosis is suggested by the combination of unexplained thrombocytopenia, anemia with a high
lactate dehydrogenase level, and RBC fragmentation on the peripheral smear. Assays for the vWF-cleaving
protease are performed in some research laboratories but are not yet routinely available.
Sepsis is one of the most common causes of thrombocytopenia in patients in intensive care units. Recent
evidence suggests that haemophagocytosis by activated monocytes and macrophages may be a major
mechanism of platelet destruction.
Drugs most commonly implicated in thrombocytopaenia include quinidine or quinine, rifampin, and
trimethoprim/sulfamethoxazole.
 HIT is a special type of drug-mediated thrombocytopenia. The mechanism involves the formation of
autoantibodies directed against heparin bound to platelet factor 4 (PF4) released from platelet granules.
The resulting antibody/heparin/PF4 immune complexes bind to platelet Fc receptors, triggering platelet
activation and clumping. There are several platelet aggregation assays available that detect the HIT
antibody.
 Thrombocytopenia can also result from abnormal sequestration or dilution.
 Massive transfusion with RBC products alone (more than 15-20 units in a 24- hour period) can result in a
dilutional thrombocytopenia.

19. Platelet Function Disorders
 Inherited platelet function disorders include Glanzmann thrombasthenia, Bernard-Soulier syndrome, and
storage pool disorders.
 Acquired causes of platelet dysfunction include drugs (aspirin, nonsteroidal antiinflammatory drugs, beta-
lactam antibiotics), uremia, myeloproliferative disorders, myelodysplasia, paraproteins, and
cardiopulmonary bypass. The diagnosis of a platelet function defect is suggested by the combination of a
prolonged bleeding time or abnormal platelet function analysis and a normal platelet count. Platelet
aggregation studies test the aggregation response of the patient’s platelets to a series of agonists. The
pattern of aggregation responses may be diagnostic of specific platelet function defects.
• von Willebrand Disease
 von Willebrand disease (vWD) is the most common inherited bleeding disorder, found in 1% of the general
population and affecting all racial and ethnic groups. It results from either a deficiency or defect in vWF,
the large multimeric protein that mediates platelet adhesion and serves as a carrier protein for FVIII [F2].
Patients with vWD present with superficial or mucosal bleeding, reflecting the defect in platelet adhesion.
The diagnosis of vWD is often suggested by abnormal screening test results, but specific assays of vWF are
required to confirm the diagnosis.
 The aPTT may be normal or slightly prolonged if the FVIII level is low (<40%). The bleeding time is usually
prolonged in severe cases but is often normal in mild cases. Platelet function analysis will be abnormal in
at least 95%.
 The diagnosis is confirmed by a panel of 3 tests: the vWF antigen level, the vWF activity level, and the FVIII
activity.
 If vWF levels are low, analysis of vWF multimers is required to determine the specific vWD subtype. The
different subtypes of vWD are distinguished based on the results of the von Willebrand panel and
multimer analysis [T3]. Various factors (trauma, surgery, estrogens, inflammation, blood group) can affect
vWF levels and complicate or confound the diagnosis. vWF levels also vary significantly over time in an
individual patient. Thus, a normal vWF panel on one occasion does not rule out vWD, and repeated testing
is often necessary to confirm or exclude the diagnosis.

20. Coagulation Disorders
 Coagulation disorders occur in inherited and acquired forms, but all result in a defect in the formation of a
fibrin clot.
 The term hemophilia refers to either of 2 clinically indistinguishable inherited clotting factor deficiencies.
Hemophilia A (FVIII deficiency) is more common, affecting 1 in 10,000 males. Hemophilia B (FIX deficiency)
affects approximately 1 in 50,000 males. Hemophilia is characterized by bleeding into joints, muscles, and
deep tissues, in contrast to the mucocutaneous pattern of bleeding characteristic of vWD and platelet
disorders. Hemophilia patients are broadly classified as having mild (>5%), moderate (1%-5%), or severe
(<1%) hemophilia based on the FVIII or FIX level.
 Severe hemophilia is usually diagnosed in early childhood, but mild hemophilia may escape detection until
adulthood, since these patients have a mild clinical course and usually bleed only with trauma or surgery.
The 4 major acquired coagulation disorders include vitamin K deficiency, liver disease, DIC, and acquired
clotting factor inhibitors.
 Deficiencies of the 4 vitamin K–dependent clotting factors (FII, FVII, FIX, FX) may result from poor nutrition,
obstructive jaundice, betalactam antibiotics, oral anticoagulants, or the ingestion of rodenticides. The
PT/INR and aPTT are both prolonged, but in the absence of other hemostatic defects, the thrombin time,
fibrinogen level, and platelet count are normal. The diagnosis is usually confirmed by correction of the
prolonged clotting times after vitamin K replacement.
 End-stage liver disease results in a multifactorial and occasionally profound failure of hemostasis due to
defects in 1 or more components of hemostasis. The PT/INR and aPTT are usually both prolonged in
advanced liver disease, reflecting the defect in clotting factor synthesis. Thrombocytopenia may be due to
splenic sequestration and impaired hepatic production of thrombopoietin.

21.  DIC is a complex derangement of the hemostatic system in which generalized activation
of coagulation causes widespread intravascular fibrin formation and subsequent
secondary fibrinolysis. Hemostatic defects predisposing to bleeding in DIC include
consumption and depletion of clotting factors, thrombocytopenia, excessive fibrinolysis,
and generation of fibrin degradation products (measured as D dimers) that interfere
with fibrin polymerization and impair platelet function.
 The laboratory findings in DIC reflect the intensity of the inciting stimulus and the
patient’s ability to compensate by synthesizing new clotting factors and platelets. In
severe DIC, the PT/INR and aPTT are usually both prolonged, the fibrinogen level and
platelet count are low, and the D-dimer level is elevated.
 Acquired FVIII inhibitors are autoantibodies against FVIII that develop spontaneously in
patients with no history of hemophilia or a bleeding disorder. The autoantibodies
(usually IgG) inactivate FVIII coagulant activity resulting in an acquired FVIII deficiency
and a severe bleeding disorder. The diagnosis should be suspected in an elderly patient
with no bleeding history who develops spontaneous bruising and soft tissue bleeding.
FVIII inhibitors are identified by an isolated prolonged aPTT, which does not correct in a
mixing study. Incubation of the mixing study at 37°C for 1 hour is required to detect
some inhibitors with slow kinetics. The FVIII level is low, and a Bethesda assay confirms
and quantifies the inhibitor.

22. Vascular Disorders
 Vascular disorders
 Ehlers-Danlos syndrome
 Amyloidosis

23. Approach To Management
 Treatment is both supportive and therapeutic
 Treat the underlying and give blood products if necessary life threatening circumstances
ITP
Aspirin and other medications that compromise platelet function should be avoided.
 Bleeding precautions (eg, restriction from physical contact activities and use of helmets) should be
observed.
 Platelet transfusion should be avoided except in circumstances of life-threatening bleeding, in which case
emergent splenectomy is to be pursued. In this setting, administration of corticosteroids and IVIG is also
advisable. Corticosteroids Patients with clinically significant but non–life-threatening bleeding (ie, epistaxis,
hematuria, and hematochezia) and those with a platelet count of less than 10,000/μL may benefit from
prednisone at 2–4 mg/kg orally per day for 3–5 days, decreasing to 1–2 mg/kg//d for a total of 14 days.
The dosage is then tapered and stopped.
 No further prednisone is given regardless of the platelet count unless significant bleeding recurs, at which
time prednisone is administered in the smallest dose that achieves resolution of bleeding episodes (usually
2.5–5 mg twice daily). Follow-up continues until the steroid can again be discontinued, spontaneous
remission.
 Intravenous Immunoglobulin (IVIG) IVIG is the treatment of choice for severe, acute bleeding, and may
also be used as an alternative or adjunct to corticosteroid treatment in both acute and chronic ITP of
childhood. IVIG may be effective even when the patient is resistant to corticosteroids; responses are
prompt and may last for several weeks

24.  Most patients receive 1 g/kg/d for 1–3 days. Infusion time is typically 4–6 hours. Platelets may be
given simultaneously during life-threatening hemorrhage but are rapidly destroyed.
 Up to 70% of patients spontaneously recover with a platelet count greater than 100,000//μL within
1 year. For the remainder, corticosteroids, IVIG, and anti-D immunoglobulin are typically effective
 Splenectomy produces a response in 70–90%, but it should be considered only after persistence of
significant thrombocytopenia for at least 1 year.
TTP
Plasma exchange with fresh frozen plasma is the therapy of choice for TTP. Octaplas is a pooled plasma
(human) that has been treated with a solvent detergent process. This blood product provides a viable
alternative to single-donor fresh-frozen plasma and provides a reduced risk of certain viral
transmissions. Replacement with normal saline and albumin is not adequate. When immediate plasma
exchange is not available, simple plasma infusion can be performed until the patient can be transferred
to a facility that performs plasma exchange.
Usually, at least five plasma exchanges are performed in the first 10 days.

25.  DIC
Treatment should primarily focus on addressing the underlying disorder. DIC can result
from numerous clinical conditions, including sepsis, trauma, obstetric emergencies,
and malignancy. Surgical management is limited to primary treatment of certain
underlying disorders.
Management of the DIC itself has the following basic features:
• Monitor vital signs
• Assess and document the extent of hemorrhage and thrombosis
• Correct hypovolemia
• Administer basic hemostatic procedures when indicated
Platelet and factor replacement should be directed not at simply correcting laboratory
abnormalities but at addressing clinically relevant bleeding or meeting procedural
needs. Heparin should be provided to those patients who demonstrate extensive fibrin
deposition without evidence of substantial hemorrhage; it is usually reserved for cases
of chronic DIC.

26. Haemophilia A
The treatment of hemophilia may involve prophylaxis, management of bleeding episodes,
treatment of factor VIII (FVIII) inhibitors, and treatment and rehabilitation of hemophilia
synovitis. Use of factor replacement products and other medications, including pain
medications, is typically required.
Dose calculations are directed toward achieving an FVIII activity level of 30-40% for most
mild hemorrhages, of at least 50% for severe bleeds (eg, from trauma) or prophylaxis of
major dental surgery or major surgery, and 80-100% in life-threatening hemorrhage
Desmopressin vasopressin analog, or 1-deamino-8-D-arginine vasopressin (DDAVP), is
considered the treatment of choice for mild and moderate hemophilia A. It is not effective
in the treatment of severe hemophilia. DDAVP stimulates a transient increase in plasma
FVIII levels.
Approaches to treating patients with FVIII inhibitors include the following:
• Porcine FVIII, which has low cross-reactivity with human FVIII antibody
• Activated prothrombin complex concentrate (PCC)
• Activated FVII
• Desensitization
• Immune tolerance induction (ITI)
• Monoclonal antibodies that bridge FIXa and FX (eg, emicizumab)

27. Indication or Site of Bleeding Factor level Desired, % FVIII Dose, IU/kg Comment
Severe epistaxis; mouth, lip,
tongue, or dental work
20-50 10-25
Joint (hip or groin) 40 20 Repeat transfusion in 24-48
Soft tissue or muscle 20-40 10-20 No therapy if site small and
not enlarging (transfuse if
enlarging)
Muscle (calf and forearm) 30-40 15-20 None
Neck or throat 50-80 25-40 None
Hematuria 40 20 Transfuse to 40% then rest
and hydration
Laceration 40 20 Transfuse until wound healed
GI or retroperitoneal
bleeding
60-80 30-40 None
Head trauma (no evidence
CNS bleeding
50 25 None
Head trauma (probable or
definite CNS bleeding, eg,
headache, vomiting,
neurologic signs)
100 50 Maintain peak and trough
factor levels at 100% and
50% for 14 d if CNS bleeding
documented†

28.  Haemophilia B
 Recombinant FIX products (eg, BeneFIX, Rixubis, Alprolix) 20 – 75 IU/KG

29. Bibliography
 Blood Journal – Approach to bleeding Patient, Jody Kujovich, MD
 Medscape
 Essential Haematology