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==DDX==
==Background==
*[[Vitamin K Deficiency]]
*Primary hemostasis: damage to endothelial basement membrane and formation of platelet plug
*[[Warfarin (Coumadin)]]
*Secondary hemostasis: coagulation cascade
*[[Heparin]]
[[File:Coagulation cascade.png|thumbnail|Coagulation cascade]]
*[[Lovenox]]
*[[DIC]]
*[[Hemophilia]]


==[[Factor VIII Inhibitor]]==
==Clinical Features==
#(PTT does not correct after mixing)
*Spontaneous [[hemorrhage|bleeding]]
#high dose Factor VII, prothrombin, or recombinant factor VIIa
*Bleeding out of proportion
*Swollen joints
*[[Epistaxis]]
*Bleeding gums
*[[vaginal Bleed Non-Pregnant|Menometrorrhagia]]
*Easy bruising/[[petechiae]]
*[[Hematuria]]


==[[Lupus Anticoagulan]]t==
==Differential Diagnosis==
#(rare)
{{Increased bleeding DDX}}
#warfarin or ASA


==[[Liver Disease Induced Coagulopathy]]==
===Increased Clotting===
===Background===
*[[Disseminated Intravascular Coagulation (DIC)]]
*PT prolongation
**Decreased synthesis of vitamin K-dependent factors (II, VII, IX, X)
*Thrombocytopenia
**Portal hypertension -> congestive hypersplenism -> splenic sequestration
*Fibrinolysis increased
**Due to decreased synthesis of alpha2 plasmin inhibitor
**Low fibrinogen level, mild elevation of FDP and D-dimer


===Treatment===
==Management==
#Lab abnormalities only (w/o significant bleeding)
*[[Bleeding Treatments]]
##Observation
*[[Procedures in patients with coagulopathies]]
#Significant bleeding
*[[Anticoagulant reversal]] (known medications)
##Vitamin K PO or IV
**[[Warfarin (Coumadin) Reversal]]
##Desmopressin
**[[Dabigatran (Pradaxa) Reversal]]
###Effective w/ minimal side effects
**[[Rivaroxaban reversal]]
###0.3 mg/kg IV (preferred) or SC (max 20mg)
**[[Unfractionated heparin reversal]]
###Onset of action ~1hr, duration of action ~4-24hr
*[[Anti-platelet agent reversal]]
##Cryoprecipitate
###May be used to replace fibrinogen in pts w/ fibrinogen levels <100
###1 bag per 10kg of body weight
##Plts
###Aim for >50K for moderate risk procedures; >100K for high risk procedures
##FFP
###Use w/ caution; requires large volume of FFP to make a significant difference
##PPI/pepcid/octreotide (variceal bleed)
 
==[[Renal Disease Induced Coagulopathy]]==
===Background===
*Uremic toxins inhibit platelet aggregation
*Dialysis filter may cause thrombocytopenia
 
===Treatment===
#Acute dialysis
##pRBCs
###Raising hct to above 25-30% improves bleeding time
##Desmopressin
###Simplest and least toxic acute treatment
###Increases release of factor VIII:von Willebrand factor multimers
###0.3 mg/kg IV (preferred) or SC (max 20mg)
###Onset of action ~1hr, duration of action ~4-24hr
#Estrogen
##Unclear mechanism of action
##Onset of action within 1d
##Options
###Conjugated estrogen 0.6mg/kg IV or 2.5-25mg PO daily
#Cryoprecipitate
##Only indicated for life-threatening bleeding resistant to DDAVP and blood tranfusion
#Plt transfusion
##Minimally effective b/c infused plts quickly acquire the uremic defect
 
==Managment==
*[[Warfarin (Coumadin) Reversal]]


==See Also==
==See Also==
*[[Bleeding Treatments]]
*[[Transfusions]]
 
*[[Idarucizumab]]
==Source==
*Tintinalli
*UpToDate


==References==
<references/>
[[Category:Heme/Onc]]
[[Category:Heme/Onc]]

Revision as of 00:16, 1 October 2019

Background

  • Primary hemostasis: damage to endothelial basement membrane and formation of platelet plug
  • Secondary hemostasis: coagulation cascade
Coagulation cascade

Clinical Features

Differential Diagnosis

Coagulopathy

Platelet Related

Factor Related

Increased Clotting

Management

See Also

References