๐ About
- ๐ Disorder of blood clotting affecting hemostasis
- โก Can be inherited (hemophilia) or acquired (liver disease, DIC, warfarin)
- ๐ฏ Results in either bleeding tendency or thrombotic complications
- ๐จ Medical emergency requiring prompt recognition and treatment
๐งฌ Aetiology
- ๐ Drug-induced: Warfarin, heparin, DOACs, aspirin, NSAIDs
- ๐ฅ Liver disease: Reduced synthesis of clotting factors
- ๐ฉธ DIC: Consumption of clotting factors and platelets
- ๐งฌ Inherited: Hemophilia A/B, von Willebrand disease
- ๐ฌ Hematological: ITP, aplastic anemia, leukemia
- ๐ Massive transfusion: Dilutional coagulopathy
- ๐ก๏ธ Hypothermia: Impaired enzymatic function
- โ๏ธ Acidosis: pH <7.2 impairs coagulation cascade
๐ฏ Correction Targets
- ๐งช Fibrinogen: >1.0 g/L (>100 mg/dL)
- ๐ด Platelets: >50 ร 10โน/L (>75 ร 10โน/L for CNS bleeding)
- โฑ๏ธ PT and APTT: <1.5 ร upper range of normal
- ๐ฉธ INR: <1.5 (ideally <1.2 for surgery)
- ๐งช D-dimer: Markedly โ in DIC
๐ฉน Clinical Presentation
๐จ Obvious Bleeding:
- ๐ฉธ PR bleeding: Rectal bleeding, melena
- ๐ด PV bleeding: Vaginal bleeding, menorrhagia
- ๐คฎ Haematemesis: Vomiting blood, coffee-ground vomit
- ๐ซ Haemoptysis: Coughing up blood
- ๐๏ธ Mucosal bleeding: Epistaxis, gingival bleeding
- ๐ต Skin: Petechiae, purpura, ecchymoses
๐ Hidden Bleeding Locations:
- ๐ซ Retroperitoneal: Back/flank pain, hypotension
- ๐ฆด Long bone fractures: Up to 1.5L blood loss
- ๐ฆด Pelvic fractures: Up to 3-4L blood loss
- ๐ฆต Thigh hematoma: Up to 2L blood loss
- ๐ช Psoas hematoma: Hip flexion, femoral nerve palsy
- ๐ฅ Rectus sheath: Abdominal pain, mass
โ ๏ธ INTRACRANIAL BLEEDING - EMERGENCY
๐ง Stroke, SDH, EDH with focal neurology or โGCS
๐จ Requires immediate reversal and neurosurgical consultation
๐ฌ Investigations
- ๐ฉธ FBC: Platelet count, hemoglobin
- โฑ๏ธ Coagulation screen: PT, APTT, INR, TT
- ๐งช Fibrinogen level: Functional clotting assessment
- ๐ฌ D-dimer: If DIC suspected
- โ๏ธ Blood gas: pH, lactate, base excess
- ๐ก๏ธ Core temperature: Hypothermia assessment
- ๐งฌ Group & save/crossmatch: For blood products
- ๐ Thromboelastography (TEG): If available for surgery
โ๏ธ Management
๐ฉธ Blood Product Therapy:
- ๐ด Platelets: 1 unit/10kg (or 4-6 units adult dose)
- ๐งช Cryoprecipitate: 1-2 units/10kg for fibrinogen
- ๐ Fresh Frozen Plasma: 10-15 mL/kg
- ๐
ฐ๏ธ Prothrombin Complex Concentrate: 25-50 units/kg
- ๐ฉธ Control bleeding source: Direct pressure, surgery, endoscopy
- ๐ฅ Resuscitation: IV access, fluids, blood products
- ๐ Specific reversal agents:
- ๐ Warfarin: Vitamin K + PCC or FFP
- ๐ Heparin: Protamine sulfate
- ๐ Dabigatran: Idarucizumab
- ๐ Rivaroxaban/Apixaban: Andexanet alfa
- ๐ก๏ธ Correct hypothermia: Active warming to >36ยฐC
- โ๏ธ Correct acidosis: Target pH >7.2
- ๐ Antifibrinolytics: Tranexamic acid 1g IV
๐จ MASSIVE HEMORRHAGE PROTOCOL
๐ Activate massive transfusion protocol
๐ฉธ Target ratio - RBC:FFP:Platelets = 1:1:1
๐ Differentials
- ๐ซ Trauma: Hemorrhagic shock from injury
- ๐ฅ GI bleeding: Peptic ulcer, variceal bleeding
- ๐ซ Pulmonary embolism: With anticoagulation
- ๐ง Intracranial hemorrhage: Spontaneous or traumatic
- ๐คฑ Obstetric hemorrhage: PPH, placental abruption
- ๐ฆ Sepsis with DIC: Consumptive coagulopathy
๐ References
- ๐ British Committee for Standards in Haematology Guidelines
- ๐ฅ NICE Clinical Guidelines - Major Haemorrhage
- ๐ Oxford Handbook of Acute Medicine 4th Edition
- ๐ฌ European Society of Cardiology Guidelines
- ๐ American Society of Hematology Guidelines