Overview in management of bleeding patients for medical students.

1. Approach to
bleeding disorder
Kaipol Takpradit

2. Covered topics
• Basic of hemostasis
• Approach to a bleeding patient
• Principle of treatment of a bleeding patient

3. Hemostasis
• Primary hemostasis
• Platelet
• Vessel constriction
• Tissue edema
• Secondary hemostasis
• Coagulation factors

4. Primary hemostasis
• Consist of platelet, vessel wall
• Initial step to stop bleeding
• Disorder usually causes superficial bleeding
(petechiae, purpura), persistent superficial bleeding

9. Platelet activation

22. Secondary
hemostasis
• Consist of coagulation factors
• Defect causes delayed (1-2 hr.) bleeding
• Usually causes deep or internal bleeding

45. Cause of bleeding
diathesis
• Local lesion e.g. gingivitis
• Vasculopathy e.g. scurvy, amyloidosis, Osler-Weber-
Rendu syndrome
• Thrombocytopenia e.g. ITP, acute leukemia
• Platelet dysfunction e.g. antiplatelet drug,
Glanzmann’s thrombasthenia, Bernard-Soulier
syndrome
• Coagulation defect e.g. VKA, hemophilia

46. Approach to
patients
• Bleeding proper to trauma?
• Bleeding is local or systemic?
• Location of bleeding?
• History of bleeding?
• Previous challenging event
• Spontaneous bleeding

47. Other
considerations
• Family history of bleeding diathesis
• Underlying diseases of the patient
• Concurrent medication
• Antiplatelet drugs
• Anticoagulant
• Drug interaction

48. Investigation
• Use to confirm or differentiate causes of bleeding
• Empirically investigation can cause a lot of headache
to treating physician
• Investigations require high-skilled technician and
prone to be error
• Due to limitation of knowledges, investigation
may not cover all aspects of coagulation system
thus may be not well correlate with clinical

49. Investigation
• Complete blood count
• Can determine the quantity of platelets
• Peripheral blood smear
• Can evaluate some quality of platelets
• Platelet aggregation test
• Can evaluate functions of platelets in presence of
certain agonists

50. Bleeding time
• Can determine overall function of vessel wall and
platelets
• Require skilled technician to apply right pressure,
site of skin puncture, size of lancet, depth, avoid
contact to punctured site, etc
• Also altered by Hct, platelet count
• Thus in overall, there is a poor correlation between
bleeding time and surgical bleeding

51. Coagulogram
• Test on sum function of all factors in the path way
• Can approximate function of coagulation but not all
• Factor X activity has very few effect on aPTT
• PT is more sensitive to factor VII and X than II and
fibrinogen level
• Factor XIII is not tested in coagulogram
• Factor XII deficiency has prolonged aPTT but has
no clinical bleeding

52. Coagulogram
• Prolonged result indicate decreased level or from
inhibition of clots formation
• Deficiency of one or more factors
• Inhibitor to factors
• Protein interfering fibrin polymerization
• Increased fibrinolysis

53. Mixing test
• At least 50% of factor’s activity can produce a
normal coagulogram
• Normal activity in plasma is 100%
• If patient’s plasma has 0% activity then mixing test
should be able to correct the coagulogram
• Normal plasma derived from pooled plasma of
normal individual

54. Mixing test
• Specific factor inhibitor is time dependent e.g. factor
VII inhibitor, factor IX inhibitor
• Unspecific inhibitor like antiphospholipid antibody
cause an immediate prolonged mixing study

55. Other test
• Venous clotting time
• Urea solubility test
• Factor assay
• Activated clotting time
• Thromboelastograph

56. Thromboelastograph

57. Principle of
treatment
• Local bleeding should be stopped by local mean
• If the cause(s) can be corrected then do so
• Antivenom for snake bite , etc.
• For deficiency of a functional component,
replacement of that component can be used
• In presence of inhibitor, try to eradicate inhibitor or
bypass the affected pathway

58. Local measure
• Compression
• Good for primary hemostatic defect
• Antifibrinolytic drug e.g. tranexamic acid
• Vasoconstrictor e.g. adrenaline
• Fibrin glue
• Surgical mean e.g. suturing, electrocauterization

59. Replacement
• Blood component
• Efficiently arrange the use of donated blood
• Can separately store each components in their
proper condition
• Good blood banking is indicated by using of
blood component

60. Replacement
• Platelet concentrate
• Contain platelet 5.5 x 1010/unit
• Raise platelet about 5,000/µL
• Contain RBC about 0.5 ml
• Contain WBC about 108-109/unit
The Thai Red Cross Society

61. Replacement
• Pooled leukocyte poor platelet concentrate
• Contain platelet 3.0 x 1011/unit
• Raise platelet about 30,000/µL
• Contain RBC about 5 ml
• Contain WBC about < 2x 108/unit
The Thai Red Cross Society

62. Replacement
• Single donor platelet
• Contain platelet ≥ 3.0 x 1011/unit
• Raise platelet about 30,000/µL
• Contain RBC about 5 ml
• Contain WBC about < 106/unit
The Thai Red Cross Society

63. Replacement
• Fresh frozen plasma
• Contain all coagulation factors
• Should be used immediately after thawed
• Supposed to have 100% activity of each factors
• 1 ml contain factor 1 unit

64. Replacement
• Cryoprecipitate
• Contain factor VIII, factor XIII, vWF, fibrinogen
• Each unit have factor VIII 80-100 units
• 1 unit/10 kg dose can raise fibrinogen 100 mg/dL
• Factor concentrates e.g. factor VIII concentrate, factor
IX concentrate, recombinant factor VIIa

65. Bypassing agent
• Prothrombin complex concentrate
• Activated prothrombin complex concentrate (FEIBA ®)
• Recombinant factor VIIa (NovoSeven ®)

66. Fin