Understanding Bleeding Disorders: A Guide for Junior Doctors

Bleeding disorders encompass a wide range of conditions that affect the blood’s ability to clot properly. For junior doctors in the emergency setting, recognizing and managing these disorders is critical, as they can range from mild to life-threatening. This blog post aims to break down the essentials of history-taking, examination findings, investigations, and management for bleeding disorders.

History Taking: Key Questions to Ask

A thorough history is the first step in identifying a bleeding disorder. Key questions include:

·       Presenting Complaint

• Site and type of bleeding: Is it spontaneous (e.g., nosebleeds, bruising) or following trauma? Ask if they’ve noticed bleeding from unusual sites such as the gums or into joints (hemarthrosis).

• Severity and duration: How long has the bleeding been occurring, and is it persistent or episodic?

• Any recent trauma or surgery? A minor cut leading to prolonged bleeding can be a red flag for a clotting disorder.

·       Past Medical History

• Previous bleeding episodes: Ask about previous hospital admissions, surgical procedures, or dental extractions that led to prolonged bleeding.

• Menstrual history: For women, heavy menstrual bleeding (menorrhagia) can be a clue.

• Family history: Any known family members with bleeding disorders such as hemophilia or von Willebrand disease?

• Medications: Are they on any anticoagulants (warfarin, heparin), antiplatelet drugs (aspirin, clopidogrel), or herbal supplements that could affect clotting?

·       Systems Review

• Easy bruising or petechiae: These can indicate platelet disorders.

• Gastrointestinal or genitourinary bleeding: Blood in stools or urine could point to internal hemorrhage.

• Joint or muscle pain: Spontaneous joint bleeding (hemarthrosis) is a hallmark of hemophilia.

Examination Findings

Physical examination can reveal important signs that guide the diagnosis of a bleeding disorder:

·       General Appearance

• Pallor: Suggestive of anemia from chronic blood loss.

• Petechiae or purpura: Small red or purple spots on the skin, common in platelet disorders.

• Ecchymosis or large bruises: Look for large areas of bruising, which can indicate coagulation factor deficiencies.

·       Specific Sites

• Oral cavity: Examine for gingival bleeding or mucosal petechiae.

• Joints and muscles: Check for swelling, tenderness, or decreased range of motion in joints (signs of hemarthrosis), especially in large joints like knees and elbows.

• Abdomen: Tenderness or distension could indicate internal bleeding, particularly in cases of liver disease affecting clotting factor production.

Investigations: Identifying the Cause

The investigation of a bleeding disorder aims to pinpoint the defect in the coagulation system.

·       Baseline Blood Tests

• Full blood count (FBC): Look for thrombocytopenia (low platelet count), which may indicate a primary platelet disorder.

• Peripheral blood smear: Helps rule out abnormal platelet morphology or the presence of schistocytes (suggestive of hemolysis).

·       Coagulation Studies

• Prothrombin time (PT) and activated partial thromboplastin time (aPTT): Prolonged PT suggests a problem in the extrinsic pathway (e.g., warfarin therapy, liver disease), while prolonged aPTT suggests an intrinsic pathway defect (e.g., hemophilia).

• Fibrinogen level and D-dimer: Decreased fibrinogen or elevated D-dimer may indicate disseminated intravascular coagulation (DIC).

·       Specific Tests

• Von Willebrand factor assay: For patients with a family history or clinical suspicion of von Willebrand disease.

• Mixing studies: If PT or aPTT is prolonged, mixing studies help distinguish between a clotting factor deficiency and the presence of an inhibitor.

• Liver function tests: In liver disease, synthesis of clotting factors is impaired.

·       Advanced Imaging

• CT scan or ultrasound: Consider imaging if internal bleeding is suspected, particularly in trauma cases or spontaneous hemorrhages.

Management Plan: Tailored to the Disorder

The management of bleeding disorders depends on the underlying cause but involves both supportive care and targeted therapy.

·       Initial Management

• Hemodynamic stabilization: If significant bleeding is present, ensure IV access, fluid resuscitation, and, if necessary, blood transfusions.

• Stop ongoing anticoagulation: If the patient is on anticoagulants, reverse these effects where appropriate (e.g., vitamin K for warfarin, protamine for heparin).

·       Specific Treatments

• Platelet disorders: Platelet transfusions may be necessary if thrombocytopenia is severe. Desmopressin (DDAVP) can be used in patients with von Willebrand disease or mild hemophilia A.

• Clotting factor deficiencies: Replace missing factors:

  • Hemophilia A or B: Factor VIII or IX concentrates.

  • Disseminated intravascular coagulation (DIC): Treat the underlying cause and consider cryoprecipitate, fresh frozen plasma, or fibrinogen concentrate as needed.

• Vitamin K deficiency: Administer vitamin K, particularly in cases related to warfarin use or malnutrition.

·       Adjunctive Measures

• Antifibrinolytics: Tranexamic acid or aminocaproic acid can be useful in stabilizing clots in mucosal bleeding or post-surgical scenarios.

• Treat the underlying cause: For example, in liver disease, focus on optimizing liver function. In DIC, treat the infection or underlying sepsis.

·       Referral

• Hematology referral: For patients with newly diagnosed or poorly controlled bleeding disorders, early referral to hematology is essential for long-term management and genetic counseling.

  
  

Bleeding disorders can be challenging to diagnose and manage, but a structured approach involving thorough history-taking, careful examination, and appropriate investigations can help junior doctors navigate these complex cases. Always stabilize the patient first and initiate specific treatment depending on the disorder's cause. Early involvement of specialists is key to preventing complications in patients with chronic bleeding disorders.