DR. KHADIJA HABIB PG TRAINEE (MCPS) PAEDIATRICS DIAGNOSTIC APPROACH TO A PATIENT PRESENTED WITH BLEEDING (IRRESPECTIVE OF AGE)
Dec 22, 2015
DR. KHADIJA HABIB PG TRAINEE (MCPS)
PAEDIATRICS
DIAGNOSTIC APPROACH TO A PATIENT PRESENTED WITH
BLEEDING(IRRESPECTIVE OF AGE)
HEMOSTASIS
Three main components of hemostasis:1. Vascular wall2. Platelets3. Coagulation cascade
Two important functions:4. To maintain the blood in fluid clot free state in
blood vessels5. To induce rapid and localized hemostatic
plug at site of injury
PRIMARY PLATELET PLUG
Platelets are responsible for primary hemostasis and carried out in 4 steps:
1. Adhesion2. Activation3. Secretion4. Aggregation
1: ADHESION
vWF
Dense granules (activation) = ADP, serotoninAlpha granules (adhesion) = PF4, PDGF, vWF, fibrinogen
GP Ib/IX/V
2: ACTIVATION
vWF
GPIa/IIa
GPIIb/IIIa
Fibrinogen
GPIIb/IIIa conformational change isInduced with epinephrine, ADP, serotonin, Arachidonic acid, thrombin
BT inc , Thrombocytopenia
BT inc , Platelet count normal
1. ITP2. TTP3. HUS4. HIT
1. Aspirin 2. Uremia
Main genetic disorders3. Bernard soulier
syndrome4. Glantzmann’s
thrombasthenia5. vWF
SUPERFICIAL BLEEDING(epistaxis , petechiae , echymosis)
BT / CBC
vWF disease1. BT inc
2. Platelets normal3. PT normal
4. aPTT raised
Work up for prolonged PT
Work up for prolonged APTT
INHERITED 1. Factor VII deficiency
ACQUIRED2. Factor VII deficiency3. Vitamin K deficiency4. Liver diseases5. Warfarin administration6. Inhibitor of factor VII
INHERITED1. Deficiency of factor VIII , IX & XI2. Deficiency of factor XII ,
prekallikrein or HMW kininogen3. VWD
ACQUIRED4. Heparin administration5. Inhibitors of factor VIII , IX , XI
& XII6. Acquired VWD7. Lupus anticoagulant
DEEP BLEEDING(hematoma , hemarthrosis)
PT / APTT
MIXING STUDIES / CORRECTION STUDIES
When abnormality in PT and APTT is detected then mixing studies is performed to rule out:
1. Presence of Inhibitor to clotting factor2. True clotting factor deficiency
2: TRUE CLOTTING FACTOR DEFICIENCY
Aged serum: (1 8 5 2)1. Factor I2. Factor VIII3. Factor V4. Factor II
Adsorbed plasma: (1 9 7 2)1. Factor X2. Factor IX3. Factor VII4. Factor II
TEST V VII VIII IX X XI or XII
PT Abnormal
Abnormal
Normal Normal Abnormal
Normal
APTT Abnormal
Normal Abnormal
Abnormal
Abnormal
Abnormal
ADSORBED PLASMA
Corrects No change
Corrects No change
No change
Corrects
AGED PLASMA
No change
Corrects No change
Corrects Corrects Corrects