Bleeding 1 and 2 Flashcards
What does a hemodynamically unstable patient look like?
Tachycardia, pale gums, altered mentation, hypothermic, may be febrile
Why could a patient be bleeding?
Primary hemostatic disorders, hemorrhage from mass (neoplasia), GI ulcerations (rimydyl), parasitism (fleas), traumatic, iatrogenic/pharmacological, toxin (xylato, sagal palm, rodentacide)
Case 1: Asher
Hisotry:
Difficulty breathing
Wound thorax
Forelimb lameness
Hepatic abscesses in past (lobectomy)
UTP vac
Free Range Property
PE:
Dyspnea, hemorrhagic sublingual and laryngeal saccule swelling, hemorrhage hard palate, elbow pain and swelling, abrasion right axillary with continuous bleeding
What are you differentials?
Anemia - Difficulty breathing, hemorrhage, liver damage
-Coagulation Disorder
-Toxin (rodenticide)
-Trauma
-Pharyngeal or laryngeal disease
-Pulmonary disease
-Cardiac disease
Forelimb lameness, wound thorax - trauma
-Neoplastic
-Coagulopathy
Swelling soft palate
-Ate a toxin or FB
What diagnostics would you recommend for Asher?
CBC
Chem
Clotting Times
X-ray or Ultrasound (Thoracic/Abdomen)
Results from diagnostics:
CBC: Normal
Chem: Normal
Thoracic X-ray: Cranial mediastinal Mass Effect (rule out neoplasia)
PTT: Increased
PT: Increased
What is higher on the differential list for Asher now?
Clotting Disorder
Toxicity
What are some of the major components of hemostasis?
Vascular Injury
-Vasoconstriction
-Collagen -> platelet activation ->vwf and fibrinogen help from a platelet plug (primary hemostasis)
-Tissue factor -> Coagulation cascade -> throbin that turns fibrinogen to fibrin to make a blood clot (secondary hemostasis)
-Antithrombotic control mechanism
Which clotting factors are part of the Intrinsic pathway? Extrinsic?
Common?
Intrinsic: XII, XI, IX, VIII (PT)
Extrinsic: III, VII, X,
Common: II, I
Which clotting factor does rodenticide effect?
Factor 7 - vitamin K dependent (2, 10, 9)
What is the treatment for Asher and his rodenticide positioning?
Vitamin K Oral or SQ
Plasma (give clotting factors we are missing)
Oxygen
Pain Management
What is the difference between the 3 main blood products and what are they?
Whole Blood - Fresh (8hrs) or stored (3-4wk)- no functional platelets, hypovolemic patient with coagulopathies, won’t get sustained platelet function
Packed Red Cells - pRBC 21 day shelf life, normovolemic, anemic patient
Frozen Plasma - FFP frozen, all coag factor and protein, < year, all coagulopathies, Stored frozen, rodenticide and hypoproteinemia
How long should Asher be treated with vitamin K?
30 days, or until he fully recovers
-Recheck PT/PTT 48-72 hours after completion vitamin K
Asher represent with pale MM, delayed CRT, dull mentation, weakness, abdominal fluid wave (shock)
Diagnostics: Ultrasound - abdominal mass effect
CBC: Normochromic, normocytic anemia, neutrophilia, lymphopenia, monocytosis, thrombocytopenia, low protien
Chem: Hyperglycemia, hyperphosphatemia, protenemia, high ck, low sodium and chloride
Poor clotting times
PCV abdominal fluid 30%
What is going on? What are your differentials?
Hemorrhage in the abdomen
-Trauma
-Coagulopathy
-Neoplasia
How would you treat Asher during his second visit?
Whole blood
(FPP and RBC if no whole blood)
Vitamin K orally (28 more days)
CT scan look neoplastic
Advanced antigoagulopahty testing considered
Case 2: Molly
HX:
Hyporoxia, dental 1 week ago
Strong pulse, pale MM, mumur, petechiation, UTD vac and preventative
meloxicam and gabapentin
PE:
Petechia
Staining/red nose
belly dark staining
What is Mollys problem list?
Petechia
Pale MM
Heart Murmur
Lethargy
Hyperoxia
What is on Mollys Differential list?
Anemia - hemolysis, heart disease, tick borne illness
Thrombocytopenia - SPUD
What diagnostics should be recommended for Molly?
CBC
Chem
Coagulation
Mollys Diagnostics
CBC: Low PCV, Low RBC, Low Platelet, Protein normal
What are the differentials for Thrombocytopenia?
Destruction - infectious disease, immune mediated, neoiplasma, inflammatory, drug
Decreased Production- Myelodysplastic, drug, immune, infecitous, heredity
Consumptive - DIC, vasculitis, envenomation, thrombosis
Sequestration - Splenomegaly, vasculitis
What is most likely to cause an extremely low platelet count?
Immune Mediated Thrombocytopenia
An ultrasound was performed on Molly:
-Hyperchoic liver nodule, splenomegaly
Rads: NSF
4DX: Negative
PCR panel - negative
What is your diagnosis?
Immune mediated thrombocytopenia
What would you treat molly with?
Immunosuppressants
Molly went home on the immune suppressants but had worsening lethargy, anorexia, vomiting and petechia and melaena
What could be going on now?
GI hemorrhage
Molly now had pale MM, dehydration of 5-7%, weak and stumbling, bruising and melena.
PCV decrease TS decrease. What may be going on?
Serious Hemorrhage
What blood product would you give molly if she is experiencing serious hemorrhage?
Whole blood
What other treatments would molly need in addition to whole blood?
Sucralfate, omeprazole
Steroids
Secondary or teritary immunosupressants (Azathioprine, cyclosporine, mcophenolate)
Vincristine
Human Immunoglobulins
