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![1. Mucocutaneous
a. Epistaxis
• Duration, frequency,
• Associated trauma (nose picking, allergy,infection)
b. Oral (bleeding after tooth brushing, after dental
extractions requiring sutures/packing)
c. Bruising (number, sites, size, raised [other than
extremities],
d. Gastrointestinal bleeding
SITES OF BLEEDING](https://image.slidesharecdn.com/anuupampptforbleedingchild-161129212247/75/Anuupam-ppt-for-bleeding-child-9-2048.jpg)
![Approach to a bleeding patient
LABORATORY WORK UP-
1) C.B.C./PLATELET COUNT
2) PERIPHERAL SMEAR- MORPHOLOGY
3) P.T. [Prothrombin time]
4) a.P.T.T. [ Activated partial thromboplastin
time]](https://image.slidesharecdn.com/anuupampptforbleedingchild-161129212247/75/Anuupam-ppt-for-bleeding-child-15-2048.jpg)
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Anuupam ppt for bleeding child
- 1.
- 2. : 1. Overview ofhemostasis 2. Clinical approach in making a diagnosis 3. LAB diagnosis 4. Review the most common bleeding conditions
- 3. Active process thatclots blood in areas of blood vessel injury yet simultaneously limits the clot size only to the areas of injury. HEMOSTASIS Components: 1. Vessel wall 2. Platelets 3. Coagulation proteins 4. Anticoagulant proteins 5. Fibrinolytics
- 4. Overview of Haemostasis INJURY CollagenExposure Platelet Adhesion and release reaction Platelet aggregation VASOCONSTRICTION Serotonin Platelet Phospolipid Thromboxane A2 ADP Primary haemostatic plug Stable haemostatic plug Tissue Factor Coagulation Thrombin Fibrin Fibrinolysis
- 5.
- 6. Protein C/S Factor 8& 5 Antithrombin 3
- 7. PRACTICAL APPROACH TOA CHILD WITH BLEEDING HISTORY HISTORY A.onset of symptoms B.Sites of bleeding C.Perinatal history D.Gynecologic bleeding E.Medication F. Diet Family history
- 8. HISTORY A)Onset- • age • acutevs chronic • Timing of bleeding-immediate vs delayed
- 9. 1. Mucocutaneous a. Epistaxis •Duration, frequency, • Associated trauma (nose picking, allergy,infection) b. Oral (bleeding after tooth brushing, after dental extractions requiring sutures/packing) c. Bruising (number, sites, size, raised [other than extremities], d. Gastrointestinal bleeding SITES OF BLEEDING
- 10. 2. Deep a. Musculoskeletal •Hemarthroses, unexplained arthropathy • Intramuscular hematomas b. Central nervous system hemorrhage c. Genitourinary tract 3. Surgical a. Minor (sutures, lacerations, poor or delayed wound healing) b. Major • Tonsillectomy and adenoidectomy • Abdominal surgery Contd……
- 11. C. Perinatal history a.Superficial (bruising, petechiae) b. Deep • Circumcision • Central nervous system bleeding • Gastrointestinal bleeding • Cephalohematoma • Unexplained anemia or hyperbilirubinemia • Delayed cord separation, bleeding after cord separation c. Vitamin K administration d. Maternal drugs
- 12. D.MEDICATIONS a. Aspirin andNSAIDS b. Anticoagulants c. Antibiotics d. Anticonvulsants E. Diet a. Vitamin K b. Vitamin C II. Family History .
- 13. PHYSICAL EXAMINATION- • Healthyand sick looking • Vitals signs and growth parameters • Joint examination for : A)chronic arthropathy B)joint laxity • Extremities examination fot thumb or radial anomalies(TAR) • Lymphadenopathy/hepatosplenomegaly
- 14. Contd……… Skin examination- • pallor, •hematoma, • petechiae, • ecchymosis, • telangiectasias, • poor wound healing,lax skin Hemarthrosis PETECHIAEECCHYMOSIS,
- 15. Approach to ableeding patient LABORATORY WORK UP- 1) C.B.C./PLATELET COUNT 2) PERIPHERAL SMEAR- MORPHOLOGY 3) P.T. [Prothrombin time] 4) a.P.T.T. [ Activated partial thromboplastin time]
- 16. Control bleeding; givefluids arrange blood;order CBC,PT,aPTT stat Normal PT,aPTT and decreased platelet Normal morphology and size of platelets Perform bone marrow examination Normal megakaryocytes Decreased megakaryocytes Peripheral platelet destruction 1. ITP 2. Alloimmune thrombocytopenia 3. Drug induced throbocytopenia 4. TTP 5. HELLP 6. Splenic sequestration 7. Others(sepsis,malignancy) Decreased production 1. Heriditary thrombocytopenia 2. Fanconi anemia 3. Myelopthisic disorders 4. Drug induced aplasia 5. Viral aplasia 6. Acquired megakaryocytic purpura
- 17. Control bleeding; givefluids arrange blood;order CBC,PT,aPTT stat Prolonged PT,aPTT and decreased platelet Prolonged PT and /or aPTT Normal platelets Sick child Healthy child Investigate for liver disease 1. Acute viral hepatitis 2. Drug induced hepatitis 3. Autoimmune hepatitis 4. Hepatotoxic agent ingestion Both PT and aPTT prolonged PT normal and PTT prolonged VIT K def • Give vit k • probiotics Clotting factor def Hemophilia A B C
- 18. Control bleeding; givefluids arrange blood;order CBC,PT,aPTT stat Healthy child Sick child Bleeding due to local factors like trauma, anatomic abnormalities Qualitative platelet defects 1. Order platelet aggregation studies 2. Order platelet surface GP analysis Compromised vascular integrity 1. Sepsis 2. Hypoxia 3. Acidosis 4. prematurity Normal PT and APTT and normal platelet counts
- 19. PT PTT FIBRINO- GEN PLATELETS FDPsClinical keys DIC ↑ ↑ ↓ ↓ ↑ Shock Liver failure ↑ ↑ ↓ N/↓ N Jaundice Vitamin K def ↑ ↑ N N N Malabsorpt ion Sepsis without shock ↑ ↑ N N ↑/N Fever DD’s for DIC
- 20. Some common bleedingconditions
- 21. Causes a) Infectious-CMV,HCV,HIV b) Vaccination c)SLE d) APLA synd e) Drugs-quinidine,sulfonamide,heparin f) CVID g) Lymphoproliferative disorder
- 22. Newly diagnosedITP-diagnosis to 3months Persistent ITP-3to 12months of diagnosis Chronic ITP->12months Corticosteroid dependence ITP-need for ongoing or repeated administration of steroid to maintain platelet count in excess of 30x109 or avoid bleeding. Severe ITP-bleeding at presentation of sufficient magnitude requiring treatment or occurrence of new bleeding symptoms requiring intervention RefractoryITP-presence of severe ITP occuring after splenectomy
- 23. MANAGEMENT GRADE 1 MINORBLEEDING FEW PETECHIAE(<100) <5 SMALL MUCOSAL BLEED Observation GRADE 2 MILD BLEEDING >100 PETECHIAE >5LARGE BRUISE(>3cm) NO MUCOSAL BLEEDS Observation Treatment in selected childred GRADE 3 MODERATE BLEEDING OVERT MUCOSAL BLEED MENORRHAGIA Intervention to reach grade1 or gr2 in selected children GRADE 4 MUCOSAL BLEEDS OR SUSPECTED INTERNAL BLEEDS INTERVENTION
- 24. DRUGS APPROX RESPONSE RESPONSE TIME TOXICITY Iv antiD 50-75mcg/kg 50-77% Within 24hrs Headache,fever IVIG 0.8-1g/kg SD >80% 1-2days Fever Prednisolone 1-2mg/kg-14d or 4mg/kg 4days ¾ patient respond depending on dose 2-7days Gastritis Wait & watch 2/3 pt improve spontaneously within 6months Days to month -
- 25. a)Children and adolscents PLTs <50,000/dl and bleeding PLTs<50,000/dl and invasive procedure PLTs <20,000/dl and marrow failure and hemorragic factors PLTs any counts,but with PLTs dysfunction plus bleeding or on an invasive procedure
- 26. Infants within thefirst 4 months of life: PLTs <1lakh/dl and bleeding PLTs<50,000/and an invasive procedure PLTs<1lakh/dl and clinically unstable PLTs any counts,but with PLTs dysfunction plus bleeding or on an invasive procedure
- 27. Caused by anabsence or decreased amount of a procoagulant – 1. VIII -Hemophilia A affects ~ 1:5000 males 2. IX -Hemophilia B affects ~ 1:30000 males 3. XI –Hemophilia C – Rare /Ethnicity
- 28. • Hallmark –HEMARTHROSIS •Easy bruising ,intramuscular hematomas,heamarthrosis • Life threatening condition like bleed into iliopsoas muscle,GI bleed
- 29. Prolonged PTT(reducedlevel of 8 & 9) Other screening test of hemostatic mechanism(platelet,bleeding time,PT)are normal. Specific assay for factors VIII & IX confirms the diagnosis
- 30. Dose calculationof r factor 8 and factor 9 Dose of factor 8 =%desired(rise in f8)xbody weight(kg)x0.5 Dose of factor 9 =%desired(rise in f9)xbody weight(kg)x1.4
- 31. Factor 8concentrates- A)Plasma -derived factor VIII as well as factor VIII/von Willebrand factor (vWf) concentrates are prepared from cyroprecipitates and contain vWf and moderately enriched factorVIII. B) Recombinant factor -concentrates are prepared in animal cell cultures using biotechnological procedures Package Sizes-250/500/1000/1,500/2,000 U/package. storage temperature for concentrates is 2–8 °C
- 32.
- 33.
- 34. VWF tethersplatelet to injured endothelium VWF serves as carrier protein for factor 8 Stored in WEIBEL PALADE BODIES in endothelial cells Facilitates its ability to bind to platelets by GP1b receptor.
- 35. Easy bruisability Epistaxis or gingival bleeding Menorrhagia Post-surgical bleeding Bleeding post-dental extraction
- 36. Sub types ofVW Type 1 Partial quantitative deficiency of vWF Type 2 Qualitative variants of vWF A - Absence of HMW vWF multimers B - Same as 2A and increased affinity for platelet gp Ib M - Abnormal function not caused by absence of HMW N - Decreased affinity for factor VIII Type 3 Complete deficiencey of vWF & Behave as Severe Hemophilia A
- 37. VWf concentrates- Desmopressin sprays antifibrinolytics
- 38.
- 39. factor XIII isresponsible for the crosslinking of fibrin to stabilize the fibrin clot, symptoms -delayed hemorrhage Typically, patients have trauma 1 day and then have a bruise or hematoma the next day. C/f mild bruising, delayed separation of the umbilical stump beyond 4 wk in neonates, poor wound healing,
- 40. screening tests –forhemostasis are normal The normal clot remains insoluble in the presence of 5M urea, whereas in a patient with XIII deficiency, the clot dissolves. The half-life of factor XIII is 5-7 days There is a heat-treated, lyophilized concentrate of coagulation factor XIII available to treat bleeding episodes or for prophylaxis.
- 42.
- 45. • Indication 1)to increaseoxygen delivery in an anemic patient 2)acute blood loss greater than 25-40% in blood volume. Dose-10ml/kg of RBC will increase Hb by 2.5-3g/dl Recommneded temp-33-35 C
- 46. Can besingle or pooled whole blood 1U/10 kg=increase upto 50,000 Stored in mechanical agitator at 22 C upto 5days
- 48. Freezing plasmaat -18 C within 8hrs of separation from whole blood Contains all coagulation factors Stored at -18C for 1yr Prior to administration—thawed at 36-38C 10-15ml/kg over 30-120mins
- 50. Contains fibrinogen(150mg/bag), factor8(80u/bag),VWf,factor 13 Highly concentrated form of plasma protein that settle down at bottom as ppte when frozen plasma is slowly thawed at 1-6 C Dose-10-20 ml/kg
- 51.