Approach To Bleeding Patient

Question 1

What lab tests are used to investigate primary haemostasis?

Answer 1

Platelet count, bleeding time, platelet function tests, and von Willebrand factor antigen/activity assays.

Question 2

What tests are used to investigate secondary haemostasis?

Answer 2

Prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time, mixing studies, and specific factor assays.

Question 3

What is Haemophilia A?

Answer 3

An X-linked recessive disorder caused by Factor VIII deficiency, resulting in deep tissue bleeding and prolonged aPTT.

Question 4

What is Haemophilia B?

Answer 4

An X-linked recessive disorder due to Factor IX deficiency, with clinical and lab findings similar to Haemophilia A.

Question 5

What is von Willebrand Disease?

Answer 5

A common inherited bleeding disorder caused by deficient or defective vWF, leading to mucosal bleeding and often a mildly prolonged aPTT.

Question 6

What is ITP (Immune Thrombocytopenic Purpura)?

Answer 6

An autoimmune condition in which antibodies destroy platelets, leading to isolated thrombocytopenia with normal coagulation tests.

Question 7

What is DIC (Disseminated Intravascular Coagulation)?

Answer 7

A consumptive coagulopathy characterized by widespread activation of clotting and bleeding, with prolonged PT, aPTT, low fibrinogen, and thrombocytopenia.

Question 8

What lab abnormality characterizes warfarin-induced bleeding?

Answer 8

Prolonged PT/INR due to decreased synthesis of vitamin K-dependent clotting factors.

Question 9

How does aspirin cause bleeding?

Answer 9

It irreversibly inhibits platelet COX-1, decreasing thromboxane A2 and impairing platelet aggregation.

Question 10

How does renal failure cause bleeding?

Answer 10

Uremic toxins impair platelet function despite a normal platelet count, leading to abnormal platelet function tests.

Question 11

What is acquired haemophilia?

Answer 11

A rare condition in which autoantibodies develop against Factor VIII, leading to an isolated prolonged aPTT that doesn’t correct with mixing.

Question 12

How does liver disease affect haemostasis?

Answer 12

It causes decreased synthesis of clotting factors and thrombocytopenia, resulting in prolonged PT and possibly aPTT.

Question 13

What is Desmopressin (DDAVP) used for?

Answer 13

To stimulate the release of stored vWF and Factor VIII in von Willebrand Disease and mild Haemophilia A.

Question 14

What is cryoprecipitate used for?

Answer 14

A blood product rich in fibrinogen, vWF, and Factor VIII used in DIC, Haemophilia A, and vWD.

Question 15

What is a mixing study?

Answer 15

A test used to differentiate between factor deficiencies (correction) and inhibitors (no correction) in prolonged aPTT.

Question 16

What are the modes of inheritance for Haemophilia A and B?

Answer 16

Both are inherited in an X-linked recessive pattern, typically affecting males.

Question 17

What is the mode of inheritance of von Willebrand Disease?

Answer 17

Usually autosomal dominant (Types 1 and 2); autosomal recessive in Type 3.

Question 18

What are the typical bleeding patterns in vWD?

Answer 18

Mucocutaneous bleeding, such as epistaxis, heavy menstruation, and gum bleeding

Question 19

What are the typical bleeding patterns in Haemophilia A/B?

Answer 19

Deep tissue bleeding, such as hemarthroses, muscle bleeds, and delayed post-trauma hemorrhage.

Question 20

What are common complications of treating bleeding disorders?

Answer 20

Inhibitor development, thrombosis (with overcorrection), allergic reactions, and infections (historically with plasma-derived products).

Question 21

1. A 17-year-old girl presents with menorrhagia and frequent nosebleeds. What bleeding disorder is most likely?
2. Labs show normal platelet count, prolonged bleeding time, and a mildly prolonged aPTT. What tests would confirm your diagnosis?
3. The patient is diagnosed with Type 1 von Willebrand Disease. What treatment would you initiate?

Answer 21

1. von Willebrand Disease
2. vWF antigen and activity assays
3. Desmopressin (DDAVP)

Question 22

1. A 65-year-old man with no bleeding history presents with large ecchymoses and soft tissue bleeds. What rare acquired disorder should be suspected?
2. aPTT is prolonged and does not correct with a mixing study. What is the underlying mechanism?
3. Name one specific treatment option to stop acute bleeding in this condition.

Answer 22

1. Acquired haemophilia
2. Autoantibodies to Factor VIII
3. Recombinant activated Factor VII (rFVIIa) or FEIBA (bypassing agent)

Question 23

1. A 12-year-old boy presents with repeated painful knee swelling after mild trauma. What bleeding disorder should be considered?
2. aPTT is prolonged; PT and platelets are normal. What specific factor assay would confirm the diagnosis?
3. The boy has severe Factor VIII deficiency. Name two complications associated with long term factor replacement therapy

Answer 23

1. Haemophilia A or B
2. Factor VIII and IX assays
3. Inhibitor development; chronic joint damage (arthropathy)

Question 24

1. A cirrhotic patient bleeds excessively after a liver biopsy. Which haemostatic pathway is most likely impaired?
2. PT and aPTT are both prolonged, with low fibrinogen and thrombocytopenia. What product(s) would you administer?
3. List one complication from excessive FFP administration is this scenario.

Answer 24

1. Impaired secondary haemostasis (due to decreased clotting factors)
2. Fresh Frozen Plasma (FFP), cryoprecipitate, and platelets
3. Fluid overload or volume overload

Question 25

1. A 72-year-old on warfarin presents with bleeding gums and a high INR. What is the immediate management step? 2. INR is 6.5, and the patient is actively bleeding. What factor replacement product would rapidly reverse the anticoagulation? 3. Name one thrombotic complication that could result from overcorrection.

Answer 25

1. Stop warfarin and give vitamin K 2. Administered prothrombin complex concentrate (PCC) 3. Thrombosis (e.g. DVT, PE, stroke)

Question 26

1. A 20-year-old woman with von Willebrand Disease undergoes dental extraction and develops prolonged bleeding. What type of bleeding is expected in vWD? 2. She received desmopressin but continues to bleed. What complication of DDAVP might explain reduced efficacy? 3. What is your next step in management?

Answer 26

1. Mucocutaneous (e.g., gum bleeding, menorrhagia, epistaxis) 2. Tachyphylaxis (diminished response after repeated doses) 3. Administer vWF-containing factor concentrate

Question 27

1. A trauma patient becomes hypotensive and develops oozing from IV lines. What diagnostic test would you prioritize? 2. PT, aPTT, and D-dimer are elevated; fibrinogen and platelets are low. Which type of haemostasis is disrupted here: primary, secondary, or both? 3. What are two immediate interventions?

Answer 27

1. Coagulation panel (PT, aPTT, fibrinogen, D-dimer, platelet count) 2. Both (consumption of platelets and clotting factors) 3. Treat underlying cause; give FFP, platelets, cryoprecipitate as needed

Question 28

1. A boy from a family with bleeding history presents with spontaneous joint swelling. Which type of haemostasis is likely impaired? 2. PT is normal, aPTT is prolonged. How would you confirm a diagnosis? 3. The child develops inhibitor antibodies to Factor VIII. How would this change his acute bleed treatment?

Answer 28

1. Secondary haemostasis (coagulation cascade) 2. Factor VIII or IX assay depending on suspected hemophilia type 3. Use bypassing agents like rFVIIa or FEIBA instead of standard factor VIII

Question 29

1. A dialysis patient on aspirin presents with GI bleeding. What are two contributors to this patient’s bleeding risk? 2. PT and aPTT are normal, but bleeding time is prolonged. What is the mechanism behind platelet dysfunction in renal failure? 3. What are two targeted treatments for bleeding in this patient?

Answer 29

1. Uremia-induced platelet dysfunction and aspirin effect 2. Uremic toxins impair platelet adhesion and aggregation 3. Desmopressin and dialysis (to remove toxins)

Question 30

1. A 6-year-old child develops sudden petechiae and bruising after a viral illness. What is the most likely diagnosis? 2. Platelet count is 15,000/mm³; PT and aPTT are normal. What does this pattern suggest: primary or secondary haemostasis defect? 3. Name one first-line and one second-line treatment option.

Answer 30

1. Immune Thrombocytopenic Purpura (ITP) 2. Primary haemostasis defect 3. First-line: corticosteroids; Second-line: IVIG or splenectomy