Download MBBS Pediatric PPT 1 Bleeding And Suspected Malignancy Lecture Notes

Approach to child with

bleeding and coagulation

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disorder

Learning objectives

? To recognize causes of bleeding in children

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? To recognize importance of history and examination
? To differentiate between platelets and coagulation disorders
Introduction

? Bleeding is a diagnostic challenge in children

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? Excessive bleeding suggest underlying bleeding disorder
? Minor bleeding is common in children
? Bleeding disorder can be inherited or acquired
? Coagulation, vascular disorder and platelet deficiency are main

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bleeding disorder

? Evaluation include history, exam and lab tests

Types of Bleeding Disorders

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? Coagulation Disorders- congenital/ acquired

? Hemophilia A (factor VII deficiency)

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? Hemophilia B (factor IX deficiency)

? von Willebrand Disease (vWD)

? Other

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? Platelet disorders

? Thrombocytopenia

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? Platelet functional defect

? Vascular

? HSP

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? Connective tissue disorder

? Scurvy
History

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? Detailed history
? Types of bleeding
? Emphasis on the child's age, sex, clinical presentation, family history
? General medical history: Malignancy, Sepsis, Drug use, Liver disease

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etc

Physical examination

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? Petechiae: Small pinhead hemorrhagic spot <3 mm
? Purpura (latin mean purple): Red or purpuric discoloration of skin

that do not blanch on pressure, size 3-10 mm

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? Ecchymosis: size >1 cm
? Hematoma: Collection of blood under skin or muscle of more than 1

cm

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? Hemarthrosis: Collection of blood in joints
Physical examination

? Mucocutaneous bleeding suggests a disorder of primary hemostasis,

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i.e. VWD or platelet dysfunction/deficiency, or a vascular disorder.

? In males, deep hematomas, hemarthroses, or evidence of chronic

joint abnormalities suggests hemophilia

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? Acquired bleeding disorders may present in the context of coexisting

illness

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? Anemia
? Thrombocytopenia
? Loose joints and lax skin

Physical examination

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? Lymphadenopathy and/or organomegaly suggest an infiltrative

process such as malignancy or a storage disease.

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? Signs of liver failure suggest acquired coagulation factor deficiencies
? Additional congenital anomalies may suggest the presence of a

syndromic bleeding disorder
Clinical features of bleeding disorder

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Clinical sign/ symptoms

Platelet/ vascular

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Coagulation factor

abnormality

deficiency

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Ecchymosis

Small and superficial

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Large and deep

Petechiae

Frequent

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Never

Mucosal haemorrhage

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Frequent

Uncommon

Muscle/ joint or internal

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Uncommon

Frequent

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hemorrhage

Bleeding after trauma/

Immediate, stops with

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Delayed(1-2 d later) does

surgery

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pressure

not stop with pressure

Example

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vWD, ITP

Hemophilia A and B

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FOR INT
Laboratory investigations

? CBC
? Peripheral smear

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? Bleeding time ? platelet no/ functions
? PT- (12?2 sec, 2, 5, 7, 10)
? aPTT- (25-40 sec- 5, 8, 9, 10, 11, 12)
? Platelet function testing

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FOR INTERNAL USE ONLY !
GC

BT

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PT

APTT

P/C

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Diagnosis

Wel

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N

N

N

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Hemophilia A

and B

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Wel

N

N

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N

Factor 7

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deficiency

Wel

N

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N

Vitamin K

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deficiency

Sick

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DIC, Liver

disease

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Wel

N

N

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ITP

Sick

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N

N

Aplastic

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anemia,

leukemia

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Wel

N

N

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N

Qualitative

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platelet defect

Lab workup

History and physical examination

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PT & APTT

Platelets

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decreased

Infections

Hypersplenism

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ITP

Abnormal PT,

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Malignancy

Abnormal

Abnormal PT

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Normal APTT

CHD

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APTT

and APTT

Anticoagulant

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Fanconi anemia

Normal PT

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Oral

therapy

TAR

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Hemophilia

anticoagulant,

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A and B

Factor VI def

liver dysfunction

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Vit K def, DIC

vWD
Clinical manifestations of hemophilia

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Hemophilia can affect any organ in the body
Early symptoms

From Childhood

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? Blue patches and bruises on the skin.

? Gum bleeds

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? Frenulum bleeds.

? Cuts and Wounds which Bleed a long time.

Early symptoms

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? Unbearable pain in Muscles and joints
? Swelling.
? With out Injury
HSP: Typical rash

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Quiz
Q1. Al of fol owing are true except

a) Intrinsic pathway of coagulation can be determined by PT

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b) PT is increased in hemophilia
c) Platelets are normal in HSP
d) None