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Coagulopathy
📋 About
- 🔍 Disorder of blood clotting affecting hemostasis
- ⚡ Can be inherited (hemophilia) or acquired (liver disease, DIC, warfarin)
- 🎯 Results in either bleeding tendency or thrombotic complications
- 🚨 Medical emergency requiring prompt recognition and treatment
🧬 Aetiology
- 💊 Drug-induced: Warfarin, heparin, DOACs, aspirin, NSAIDs
- 🏥 Liver disease: Reduced synthesis of clotting factors
- 🩸 DIC: Consumption of clotting factors and platelets
- 🧬 Inherited: Hemophilia A/B, von Willebrand disease
- 🔬 Hematological: ITP, aplastic anemia, leukemia
- 💉 Massive transfusion: Dilutional coagulopathy
- 🌡️ Hypothermia: Impaired enzymatic function
- ⚗️ Acidosis: pH <7.2 impairs coagulation cascade
🎯 Correction Targets
- 🧪 Fibrinogen: >1.0 g/L (>100 mg/dL)
- 🔴 Platelets: >50 × 10⁹/L (>75 × 10⁹/L for CNS bleeding)
- ⏱️ PT and APTT: <1.5 × upper range of normal
- 🩸 INR: <1.5 (ideally <1.2 for surgery)
- 🧪 D-dimer: Markedly ↑ in DIC
🩹 Clinical Presentation
🚨 Obvious Bleeding:
- 🩸 PR bleeding: Rectal bleeding, melena
- 🔴 PV bleeding: Vaginal bleeding, menorrhagia
- 🤮 Haematemesis: Vomiting blood, coffee-ground vomit
- 🫁 Haemoptysis: Coughing up blood
- 👁️ Mucosal bleeding: Epistaxis, gingival bleeding
- 🔵 Skin: Petechiae, purpura, ecchymoses
🔍 Hidden Bleeding Locations:
- 🫘 Retroperitoneal: Back/flank pain, hypotension
- 🦴 Long bone fractures: Up to 1.5L blood loss
- 🦴 Pelvic fractures: Up to 3-4L blood loss
- 🦵 Thigh hematoma: Up to 2L blood loss
- 💪 Psoas hematoma: Hip flexion, femoral nerve palsy
- 🏥 Rectus sheath: Abdominal pain, mass
⚠️ INTRACRANIAL BLEEDING - EMERGENCY
🧠 Stroke, SDH, EDH with focal neurology or ↓GCS
🚨 Requires immediate reversal and neurosurgical consultation
🧠 Stroke, SDH, EDH with focal neurology or ↓GCS
🚨 Requires immediate reversal and neurosurgical consultation
🔬 Investigations
- 🩸 FBC: Platelet count, hemoglobin
- ⏱️ Coagulation screen: PT, APTT, INR, TT
- 🧪 Fibrinogen level: Functional clotting assessment
- 🔬 D-dimer: If DIC suspected
- ⚗️ Blood gas: pH, lactate, base excess
- 🌡️ Core temperature: Hypothermia assessment
- 🧬 Group & save/crossmatch: For blood products
- 📊 Thromboelastography (TEG): If available for surgery
⚕️ Management
🩸 Blood Product Therapy:
- 🔴 Platelets: 1 unit/10kg (or 4-6 units adult dose)
- 🧪 Cryoprecipitate: 1-2 units/10kg for fibrinogen
- 💉 Fresh Frozen Plasma: 10-15 mL/kg
- 🅰️ Prothrombin Complex Concentrate: 25-50 units/kg
- 🩸 Control bleeding source: Direct pressure, surgery, endoscopy
- 🏥 Resuscitation: IV access, fluids, blood products
- 💊 Specific reversal agents:
- 🔄 Warfarin: Vitamin K + PCC or FFP
- 🔄 Heparin: Protamine sulfate
- 🔄 Dabigatran: Idarucizumab
- 🔄 Rivaroxaban/Apixaban: Andexanet alfa
- 🌡️ Correct hypothermia: Active warming to >36°C
- ⚗️ Correct acidosis: Target pH >7.2
- 💊 Antifibrinolytics: Tranexamic acid 1g IV
🚨 MASSIVE HEMORRHAGE PROTOCOL
📞 Activate massive transfusion protocol
🩸 Target ratio - RBC:FFP:Platelets = 1:1:1
📞 Activate massive transfusion protocol
🩸 Target ratio - RBC:FFP:Platelets = 1:1:1
🔍 Differentials
- 🫀 Trauma: Hemorrhagic shock from injury
- 🏥 GI bleeding: Peptic ulcer, variceal bleeding
- 🫁 Pulmonary embolism: With anticoagulation
- 🧠 Intracranial hemorrhage: Spontaneous or traumatic
- 🤱 Obstetric hemorrhage: PPH, placental abruption
- 🦠 Sepsis with DIC: Consumptive coagulopathy
📚 References
- 📖 British Committee for Standards in Haematology Guidelines
- 🏥 NICE Clinical Guidelines - Major Haemorrhage
- 📕 Oxford Handbook of Acute Medicine 4th Edition
- 🔬 European Society of Cardiology Guidelines
- 📋 American Society of Hematology Guidelines
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