DIAGNOSTIC APPROACH TO A PATIENT

PRESENTED WITH BLEEDING

(IRRESPECTIVE OF AGE)

DR. KHADIJA HABIB

PG TRAINEE (MCPS)
PAEDIATRICS

HEMOSTASIS
Three main components of hemostasis:
1. Vascular wall
2. Platelets
3. Coagulation cascade

Two important functions:

4. To maintain the blood in fluid clot free state in blood
vessels
5. To induce rapid and localized hemostatic plug at site
of injury

PROCOAGULANT =
TXA2

ANTICOAGULANT = PGI2
& NO

HEMOSTATIC PLUG

PRIMARY PLUG

PLATELETS

SECONDARY PLUG

COAGULATION
CASCADE

PRIMARY PLATELET PLUG

Platelets are responsible for primary hemostasis and

carried out in 4 steps:
Adhesion
2. Activation
3. Secretion
4. Aggregation
1.

1: ADHESION
Dense granules (activation) = ADP, serotonin
Alpha granules (adhesion) = PF4, PDGF,
vWF, fibrinogen

GP Ib/IX/V
vWF

2: ACTIVATION
GPIIb/IIIa conformational change is
Induced with epinephrine, ADP, serotonin,
Arachidonic acid, thrombin
GPIIb/IIIa
Fibrinogen
GPIa/IIa
vWF

3: AGGREGATION

GpIIb/IIa
vWF
Collagen

SECONDARY HEMOSTATIC PLUG

(Coagulation proteins)

SUPERFICIAL BLEEDING
(epistaxis , petechiae , echymosis)
BT
/ CBC

BT inc , Platelet count normal

BT inc , Thrombocytopenia
1.
2.
3.
4.

ITP
TTP
HUS
HIT

vWF disease
2.
1. BT inc
Main genetic
2. disorders
Platelets normal
3.
Bernard soulier syndrome
3. PT normal
4.
Glantzmanns thrombasthenia
5.
vWF 4. aPTT raised
1.

Aspirin
Uremia

DEEP BLEEDING
(hematoma , hemarthrosis)
PT

Work up for prolonged PT

INHERITED
1.
Factor VII deficiency
ACQUIRED
2.
Factor VII deficiency
3.
Vitamin K deficiency
4.
Liver diseases
5.
Warfarin administration
6.
Inhibitor of factor VII

APTT

Work up for prolonged

APTT
INHERITED
1. Deficiency of factor VIII , IX & XI
2. Deficiency of factor XII , prekallikrein
or HMW kininogen
3. VWD
ACQUIRED
4. Heparin administration
5. Inhibitors of factor VIII , IX , XI &
XII
6. Acquired VWD
7. Lupus anticoagulant

MIXING STUDIES / CORRECTION

STUDIES

When abnormality in PT and APTT is detected then mixing

studies is performed to rule out:

Presence of Inhibitor to clotting factor

2. True clotting factor deficiency
1.

1: PRESENCE OF INHIBITOR TO CLOTTING

FACTOR

2: TRUE CLOTTING FACTOR DEFICIENCY

Aged serum: (1 8 5 2)
1.
Factor I
2.
Factor VIII
3.
Factor V
4.
Factor II

Adsorbed plasma: (1 9 7 2)
1.
2.
3.
4.

Factor X
Factor IX
Factor VII
Factor II

TEST

VII

PT

Abnormal

APTT

Abnormal

ADSORB Corrects
ED
PLASMA

IX

XI or XII

Abnormal Normal

Normal

Abnormal

Normal

Normal

Abnormal

Abnormal

Abnormal

Abnormal

No
change

Corrects

No change No change Corrects

AGED
No change Corrects
PLASMA

VIII

No change Corrects

Corrects

Corrects