gemc- hemostasis: platelet and coagulation disorders- resident training
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This is a lecture by Dr. Joseph Hartmann from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.TRANSCRIPT
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Project: Ghana Emergency Medicine Collaborative Document Title: Hemostasis: Platelet and Coagulation Disorders Author(s): Joseph H. Hartmann (University of Michigan), DO 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
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Hemostasis: Platelet and Coagula4on Disorders
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vasculature
platelets coagulation pathway
4 Tleonardi, Wikimedia Commons
Kelvinsong, Wikimedia Commons
GrahamColm, Wikimedia Commons
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5 Steinsky, Wikimedia Commons
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6 Source undetermined
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¡ Mediated by tissue factors
¡ Affords a rapid response
¡ Prolonged prothrombin time (PT)
¡ Involves factors II, VII, IX, and X § Vitamin K dependent (coenzyme)
¡ Inhibition of vitamin K with warfarin 7
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¡ Mediated by surface contact factors
¡ Slower responder
¡ Prolonged partial thromboplastin time (aPTT)
¡ Involves factors VIII, IX, and XI § Accounts for 99% of inherited bleeding disorders ▪ Hemophilia A – factor VIII ▪ Hemophilia B – factor IX ▪ Hemophilia C – factor XI
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¡ Prolonged PT and aPTT
¡ Thrombin and fibrinogen form insoluble clot
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¡ Thrombocytopenia = platelet count < 100,000 cu mm ¡ Platelet count < 50,000 variable risk ¡ Platelet count < 20,000 transfusion appropriate ¡ Platelet count < 10,000 spontaneous hemorrhage ¡ Platelet dysfunction = mucus membrane bleeding
§ Epistaxis § Gingival § Vaginal bleeding § Petechiae, purpura
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UBC Dermatology
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Source undetermined
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¡ Immune (Idiopathic) Thrombocytopenic Purpura (ITP)
¡ Thrombotic Thrombocytopenic Purpura (TTP)
¡ Hemolytic-Uremic Syndrome (HUS)
¡ Heparin –Induced Thrombocytopenia (HIT)
¡ Drug-Induced Inactivation of Platelets
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¡ Acquired autoimmune disorder § Thrombocytopenia with normal bone marrow
¡ Acute form § Children 2-6 yrs. old § Associated with prior viral illness (<3 wk) § Resolution > 1-2 months, often quite longer § Spontaneous resolution in 90%
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¡ Chronic form § Adults: women > men or women < men § Associated with autoimmune disorder (SLE, HIV) § Resolution is rare § Thrombocytopenia < 20,000 § Mucosal bleeding
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Source undetermined
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¡ Management § Do not transfuse platelets § Steroids § Splenectomy § Immunoglobulin therapy § Plasmapheresis
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¡ Thrombocytopenia + microangiopathic hemolytic anemia
¡ Classic pentad - § Fever, anemia, thrombocytopenia, renal failure, neurologic
symptoms
¡ Associations – § Autoimmune – AIDS, lupus, scleroderma, Sjogren § Pregnancy § Rx – cyclosporine, tacrolimus, quinidine
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¡ Laboratory findings § Schistocytes (helmet cells) ▪ Intravascular hemolysis – peripheral smear
§ Platelets < 20,000 § Increased reticulocyte count § Increased indirect bilirubin § Increased LDH § Decreased haptoglobin
¡ Tx: urgent hematology consult, plasmapheresis, steroids
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Wadsworth Center
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Source undetermined
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¡ Thrombocytopenia + microangiopathic hemolytic anemia + acute renal failure
¡ Primarily in children 6 mo – 4 yr § Most common cause of acute renal failure in children
¡ Associations – § E. coli H7:0157 Shiga-like toxin
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¡ Presentation – bloody diarrhea and seizure § Pentad of TTP § TTP – neurologic symptoms more pronounced § HUS – renal dysfunction more pronounced
¡ Laboratory findings § SCHISTOCYTES § TTP lab findings § Worse renal function parameters, i.e. renal failure
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¡ Treatment § Supportive, dialysis (?), do not administer antibiotics.
Schistocytes + child = HUS Schistocytes + adult = TTP Schistocytes + neurologic dysfunction = TTP Schistocytes + renal dysfunction = HUS
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¡ Type I § Platelet count rarely < 100,000 § Occurs within first few days § Benign – not associated with thrombosis § Platelet count normalizes regardless of heparin use / disuse
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¡ Type II § Autoimmune and consumptive § Occurs day 4-14 § 1/3 of cases associated with thrombosis § Must d/c heparin No LMW heparins § No platelet transfusions unless life-threatening bleeding § Treat with direct thrombin inhibitors ▪ Hirudin (Revasc) ▪ Lepirudin (Refludan) ▪ Argatroban (Novastan)
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¡ Most common § Quinidine / quinine, sulfonamides. Phenytoin, ASA
¡ Less common § Chronic EtOH, NSAID’s (indomethacin), valproic acid
¡ Development of antiplatelet antibodies
¡ Treatment § Recovery within one week § Steroids § DDAVP / platelet transfusions for severe hemorrhage
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¡ Hemophilia A (classic hemophilia)
¡ Hemophilia B (Christmas disease)
¡ Disseminated Intravascular Coagulation
¡ von Willibrand’s Disease
¡ Medication toxicity
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¡ X-linked recessive bleeding disorder due to deficiency of factor VIII function
¡ Spontaneous genetic mutations occur accounting 1/3 of new cases ¡ Severity of disease dependent on % factor VIII
activity function § Classified as mild, moderate, severe
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¡ Severe – spontaneous bleeding § < 1% factor VIII activity
¡ Moderate – occasional spontaneous bleeding but more commonly follows trauma / surgery § 1% - 5% factor VIII activity
¡ Mild – occasional hemorrhage after dental extractions, menses § >5% factor VIII activity
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¡ 90% of bleeding events involve § Joints – knee involvement > 50% § Intramuscular – neuro-vascular compromise possible
¡ Bleeding manifestations can be delayed for hours – though normally seen within 8 hrs
¡ Minor lacerations and abrasions not normally problematic
¡ Head injuries are treated without waiting for CT ¡ Believe the patient !
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¡ Laboratory findings § PTT increased unless > 30% factor activity present § Specific factor assays necessary § Inhibitor may be present in 10-25% of patients ▪ Antibody against factor VIII
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¡ Treatment § Recombinant factor VIII – therapy of choice - $$$$$ ▪ each IU/kg increases factor VIII by 2%
§ Factor VIII concentrate –pooled donors (infection risk) § Major life-threatening bleeding 50 IU/kg initially § Hemarthrosis / muscle bleeding 25-50 IU/kg § Minor bleeding 12.5 – 25 IU/kg § Desmopressin (DDAVP) – mild to moderate disease ▪ Stimulates increase of functional factor VIII by 3-5 fold ▪ Onset 30 min; dose 0.3 microgram/kg IV
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¡ Treatment (cont) § Fresh frozen plasma contains one IU/ml of factor VIII ▪ 250 ml/bag [14 bags = 3500ml]
§ Cryoprecipitate contains 100 IU of factor VIII per bag ▪ 80-100 ml bag [35+ bags = 3500ml]
§ FFP and/or cryoprecipitate should be used only as temporizing measures if recombinant or concentrate factor VIII not available
¡ Get a consulting hematologist on board early to direct treatment choices and dosing.
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¡ X-linked recessive bleeding disorder due to deficiency of factor IX function
¡ Classification is same as Hemophilia A
¡ Clinical presentation is same as Hemophilia A
¡ Inhibitor to factor IX found < 2% of patients
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¡ Treatment § Recombinant factor IX, if available § Factor IX concentrate (pooled = infection risk) § Both factor products increase factor IX by 1% for each
IU/kg § Fresh frozen plasma contains 1 IU/ml of factor IX § Cryoprecipitate - no factor IX § Desmopressin (DDAVP) ineffective
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¡ Consumptive coagulopathy – hemostasis gone wild
¡ Simultaneous coagulation and fibrinolytic pathways promoting both bleeding and thrombotic components – one predominates
¡ Etiology: § Infection – most common, esp. gram neg sepsis § Carcinoma / leukemia § Trauma, hepatic dz, pregnancy, ARDS, viper envenom-
ation, transfusion reaction
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¡ Laboratory – § PT elevated, PTT often elevated § Decreased platelets, fibrinogen § Increased fibrin split products and d-dimer (more
specific, less sensitive) § Fragmented RBC’s anemia
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¡ Treatment § Supportive aggressive resuscitation ▪ IV fluids and RBC transfusion
§ Fresh frozen plasma to replace coagulation factors ▪ Two units at a time
§ Cryoprecipitate for fibrinogen replacement ▪ Ten bags
§ Platelet transfusion § Heparin if thrombosis predominates ▪ Ca, leukemia, pregnancy-related
§ Activated protein C, if septic shock 39
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¡ Most common inherited bleeding disorder
¡ von Willibrand’s factor (vWF) facilitates platelet adhesion to each other and to damaged endothelium § Also, a carrier protein for factor VIII
¡ Three forms of clinical presentation
¡ Laboratory – usually normal PT and PTT; bleeding time prolonged; vWF activity low
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¡ Type I § Mild form = 80% of patients § Mucosal bleeding – decrease in vWF (quantitative)
¡ Type II § Mild form =10% of patients § Mucosal bleeding – dysfunctional vWF (qualitaitve)
¡ Type III § Severe form =10% of patients § Bleeding episodes resemble hemophilias – no
detectable vWF
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¡ Treatment § Desmopressin (DDAVP) – stimulates endothelial cells
to secrete stored vWF ▪ 0.3 microgram / kg IV or SC over 30 min q 12 hr ▪ Concentrated intranasal form ▪ 1 spray in one nostril (150 micrograms) in children > 5 y/o ▪ 1 spray each nostril (300 micrograms) in adolescent / adult
§ Factor VIII concentrates 20-30 IU/kg for nonresponder Type I or Type II and III
§ Cryoprecipitate 1-2 bags / 10 kg
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¡ Warfarin § Vitamin K 1.0-2.5 mg po ▪ 10 mg slow IV for severe hemorrhage
§ Fresh frozen plasma 2-4 units ▪ 4-6 units for severe hemorrhage
§ Prothrombin complex concentrate ▪ 8.8 units/kg IV up to 500 units
§ Recombinant factor VIIa (NovoSeven) ▪ 15-20 micrograms / kg IV over 3-5 min
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¡ Protamine sulfate § 1 mg per 100 units of infused heparin in previous 4 hrs
IV over 10 min (no more than 50 mg) ¡ Low molecular weight heparin (partial reversal)
§ 1 mg per 1 mg of enoxaparin § 1 mg per 100 anti-Xa units of dalteparin
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¡ Cryoprecipitate 10 units IV ¡ Fresh frozen plasma 2 units IV ¡ Platelet transfusion 6 units IV (?) ¡ Aminocaproic acid (Amicar) 6 mg IV or po q 4hr ¡ Recombinant factor VIIa (NovoSeven)
§ 40-160 micrograms / kg IV over 1-2 min
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¡ Vitamin K 10 mg SC or IV ¡ Fresh frozen plasma 10-25 ml / kg ¡ Platelet transfusion ¡ Desmopressin (DDAVP)
§ 0.3 microgram / kg SC or § 0.3 microgram / kg in 50 ml NS IVPB over 30 min
¡ Cryoprecipitate if fibrinogen levels < 100 mg/dl
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¡ Hemodialysis provides transient benefit to platelet function for 24 – 48 hrs
¡ Desmopressin (DDAVP) § 0.3 micrograms / kg in 50 ml NS IVPB over 30 min
¡ Platelet transfusion ¡ Cryoprecipitate
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¡ ASA, NSAID’s, clopidogrel (Plavix), ticlopidine (Ticlid) § All inhibit platelet aggregation
¡ Discontinue agent ¡ Platelet transfusion ¡ Desmopressin (DDAVP)
§ 0.3 micrograms / kg in 50 ml NS IVPB over 30 min
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