Bruising Flashcards
Define bruising and easy bruising
Bruising = haematoma that forms due to bleeding under intact skin into subcutaneous tissue, caused by vascular damage or injury
Easy bruising = no significant trauma has occurred to the skin or SC tissue, and bruises are larger or more frequently seen than normal
What is the normal pattern of bruising
Red discolouration that does not blanch on pressure
Colour darkens to purple
Fades to a brown-yellow
Disappears within 2-3 weeks
HOWEVER The colour of a bruise is not a reliable indicator of the age, and there is wide variability in the appearance healing of a bruise, especially in people with darker skin tones
What are the causes of bruising
Trauma (accidental or NAI)
Platelet: Idiopathic thrombocytopenic purpura, henoch-schonlein purpura, malignancy with bone marrow involvement, aplastic anaemia, neuroblastoma, myeloma, liver disease
Coagulopathies: haemophilia A/B, VWD, amyloidosis, liver disease, vit K deficiency
Vascular: Ehlers-Danlos, Osteogenesis imperfecta, scurvy, hereditary haemorrhagic telengiectasia
Drugs e.g. corticosteroids, aspirin, NSAIDs, clopidogrel, alcohol, cephalosporins, nitrofurantoin, warfarin, heparins, DOACs
What features in the history may suggest easy bruising
Cephalhaematoma after instrumental delivery.
Unexpected bleeding from the umbilical stump or delayed stump separation by up to 4 weeks, suggesting factor XIII deficiency.
Haematoma after routine intramuscular vitamin K given at birth.
Bleeding from the newborn heel prick test, suggesting factor XIII deficiency, or sometimes haemophilia.
Recurrent nosebleeds/gingival bleeding
What are the broad categories for causes of thrombocytopenia
Increased platelet destruction/consumption: immune or non-immune
Impaired platelet production: congenital or acquired
Platelet dysfunction: congenital acquired
What are the causes of thrombocytopenia caused by increased platelet destruction/consumption
Immune: Idiopathic thrombocytopenic purpura (TP), SLE, alloimmune neonatal thrombocytopenia
Non-immunes: HUS, TTP, DIC, congenital heart disease, giant haemangioma (Kasabach-Merritt), hypersplenism
What are the causes of thrombocytopenia caused by impaired platelet production
Congenital: Fanconi anaemia, Wiskott-aldrich syndrome, Bernard-Soulier syndrome
Acquired: aplastic anaemia, marrow infiltration (leukaemia), drug-induced
What are the causes of platelet dysfunction
Congenital: Glanzmann thrombasthenia, Hermansky-Pudlak syndrome type 2
Acquired: uraemia, cardiopulmonary bypass
What bruising pattern suggests accidental injury
Small <15mm
Oval to round in shape with non-distinct borders
Located above or near bony prominences on the front of body e.g. forehead, knees, shins
What bruising patterns suggest non-accidental injury
Bruising in children who are not independently mobile
Bruising in babies (especially <6 months)
Bruises that are seen away from bony prominences
Bruises to the face, back, abdomen, arms, buttocks, ears, and hands
Multiple bruises in clusters
Multiple bruises of uniform shape e.g. hand, teeth, grip
Bruises that carry the imprint of implement used or a ligature
What are the red flags for bruising
disproportional bruising (a large bruise after a minor trauma)
bruises that can’t be explained by actual trauma
bruises that last longer than a couple weeks
nosebleeds that last longer than 10 minutes and don’t respond to pressure
excessive bleeding after surgery, dental work, or another minor procedure
bruises on young children before they learn to crawl or walk
bruising in unusual places (chest, back, face, ears, etc.)
FHx of blood disorders
Define haemophilia
Bleeding disorder/diathesis which resulting from an inherited deficiency of a clotting factor
Haemophilia A: Deficiency in factor VIII (most common)
Haemophilia B: Deficiency in factor IX (Christmas disease)
Haemophilia C: Deficiency in factor XI (rare)
What is the aetiology of haemophilia
X-linked recessive → boys/men are exclusively affected
Female carriers have clotting factors in the haemophilia range due to lyonization (random inactivation of X Chr) → bleeding symptoms
Acquired haemophilia - auto-immune aetiology, auto-antibody formation to most commonly FVIII
Note: haemophilia in girls = lyonization, homozygosity, mosaicism, turner’s syndrome
What are the risk factors for haemophilia
Family history of haemophilia
Male sex
Age >60
Autoimmune disorders, inflammatory bowel disease, diabetes, hepatitis, pregnancy, postnatal, or malignancy (acquired haemophilia)
What are the symptoms of haemophilia
Recurrent, severe, prolonged bleeding (spontaneous or trauma)
- Excessive bleeding after surgery, dental procedures
- Recurrent nasal/oral mucosal bleeding
- Excessive bruising
Bleeding into muscles → pain and swelling, reduced ROM, erythema, warmth
Haemarthrosis
- Seen when starting to walk
- Knee: pain, reduced ROM, warmth
Intracranial bleeds → hypoactivity, decreased oral intake, irritability, bulging/tense fontanelle, seizures, pallor, focal neuro deficits, headache, vomiting
Fatigue
