12 hemorrhagic syndromes

8/7/2019 12 Hemorrhagic Syndromes

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HAEMORRHAGICSYNDROMES


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ETIOLOGYETIOLOGY

Deterioration of the relationshipDeterioration of the relationshipbetween thrombocytes and vesselsbetween thrombocytes and vessels

Thrombocytopenias/pathiesThrombocytopenias/pathies

Coagulation disordersCoagulation disorders


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THE BLEEDING SYNDROMETHE BLEEDING SYNDROME

DISORDERS OF THE PRIMARYDISORDERS OF THE PRIMARY

HAEMOSTASISHAEMOSTASIS

CoutaneousCoutaneous mucous Purplemucous Purple

PetechiaesPetechiaes

EcchymosisEcchymosis


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THE BLEEDING SYNDROMETHE BLEEDING SYNDROME

DISORDERS OF THE SECONDARYDISORDERS OF THE SECONDARYHAEMOSTASISHAEMOSTASIS

Haemorrhages in deep tissues ( joints,Haemorrhages in deep tissues ( joints,retroperithoneal, CNS, ORL)retroperithoneal, CNS, ORL)

Disorders of the coagulation cascade:Disorders of the coagulation cascade:haemophilias, low levels of vitamine K,haemophilias, low levels of vitamine K,fibrinolysisfibrinolysis


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THE PRIMARY HAEMOSTASISTHE PRIMARY HAEMOSTASIS

Bleeding time > 10 min.Bleeding time > 10 min.

Thrombocytes:Thrombocytes:= 100.000/mm= 100.000/mm33 withoutwithout

symptomssymptoms

> 50.000/mm> 50.000/mm33 with symptomswith symptoms

< 20.000/mm< 20.000/mm33 spontaneousspontaneoushaemorrhagehaemorrhage

( risk of internal bleeding)( risk of internal bleeding)


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THE SECONDARY HAEMOSTASISTHE SECONDARY HAEMOSTASIS

PTT = Partial thromboplastin time (30PTT = Partial thromboplastin time (30 40 sec.)40 sec.)

PT = prothrombin time (10PT = prothrombin time (10 14 sec)14 sec) TT = thrombin timeTT = thrombin time

FibrinogenFibrinogen

Clots solubility in 5 M urea solution ( theClots solubility in 5 M urea solution ( the

wholeclot is persisting after 2 hours)wholeclot is persisting after 2 hours) Lysis of euglobinic clotLysis of euglobinic clot


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I. THROMBOCYTOPENIC PURPLEI. THROMBOCYTOPENIC PURPLE

Petechial purple (coutaneousPetechial purple (coutaneous--mucous):mucous):smooth painless petechiaessmooth painless petechiaes

Thrombocytopenia through central mechanismThrombocytopenia through central mechanism(medullar insufficiency) or peripherical(medullar insufficiency) or peripherical

mechanism (hyperfunction of the spleen,mechanism (hyperfunction of the spleen,IVDC)IVDC)

Prolonged bleeding timeProlonged bleeding time

Deficit in clots retractionDeficit in clots retraction

Immunology tests: natural antibodies (lysins,Immunology tests: natural antibodies (lysins,aglutinins), complement fixing antibodiesaglutinins), complement fixing antibodies

ETIOLOGYETIOLOGY

Idiopathic, viral, autoimmune, isoimmuneIdiopathic, viral, autoimmune, isoimmune


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I. THROMBOCYTOPENIC PURPLEI. THROMBOCYTOPENIC PURPLE

TREATMENTTREATMENT

Corticotherapy +/Corticotherapy +/-- immunoimmuno--suppressionsuppression

Spleenectomy: no response to cortisone, spleenSpleenectomy: no response to cortisone, spleenhyperfunctionhyperfunction

Immunoglobulins I.v. 400 mg/kg/dayImmunoglobulins I.v. 400 mg/kg/day


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II. DISORDERS OF COAGULATIONII. DISORDERS OF COAGULATION

A.A. HAEMOPHILIAHAEMOPHILIA

Clinical features: bleedings in soft tissues /Clinical features: bleedings in soft tissues /

musclesmuscles Lab features:Lab features: thrombocytes = Nthrombocytes = N

bleeding time = Nbleeding time = N

PT = NPT = N

PTT = prolongedPTT = prolongedlow prothrombin consumptionlow prothrombin consumption

Factor VIII (N.V. = 10 g/l) and IX are correlatingFactor VIII (N.V. = 10 g/l) and IX are correlating

with severitywith severity


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A.A. HAEMOPHILIAHAEMOPHILIA

TREATMENTTREATMENT

Cryoprecipitate enriched with factor VIIICryoprecipitate enriched with factor VIII

Local: sponges with fibrin, thrombin,Local: sponges with fibrin, thrombin,compressive bandagecompressive bandage

Adjuvant: cortisone, pain killersAdjuvant: cortisone, pain killers

Orthopedic surgeryOrthopedic surgery


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B.B. LIVER DISEASESLIVER DISEASES

Targets: prothrombinic complex, C and S proteins,Targets: prothrombinic complex, C and S proteins,fibrinogen, antithrombin III, factor Vfibrinogen, antithrombin III, factor V

Digestive bleedings: oesophagus varicose,Digestive bleedings: oesophagus varicose,

ulcerationsulcerations Lab features: PT = prolongedLab features: PT = prolonged

PTT = prolongedPTT = prolonged

fibrinogen = lowfibrinogen = low

thrombocytopeniathrombocytopenia

Treatment : fresh plasma, prothrombinicTreatment : fresh plasma, prothrombinicconcentratesconcentrates

(in IVDC: heparin and then plasma)(in IVDC: heparin and then plasma)


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C.C. IVDCIVDC

Systemic coagulation in the microcirculationSystemic coagulation in the microcirculation

Consumption of thrombocytes and coagulationConsumption of thrombocytes and coagulationfactorsfactors

Exaggerated fibrinolysis:Exaggerated fibrinolysis:

-- cutaneous and mucous bleeding lesionscutaneous and mucous bleeding lesions

-- peripherical acrocyanosisperipherical acrocyanosis

-- thrombosis, pregangrenous lesionsthrombosis, pregangrenous lesions


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C.C. IVDCIVDC

ETIOLOGYETIOLOGY

Important traumatismsImportant traumatisms

Obstetrical accidentsObstetrical accidents

MetastasisMetastasis SepticaemiaSepticaemia

LAB FEATURESLAB FEATURES

Thrombocytes and fibrinogen = lowThrombocytes and fibrinogen = low PT, TT, PTT = prolongedPT, TT, PTT = prolonged

Products of degradation of fibrin = highProducts of degradation of fibrin = high


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C.C. IVDCIVDC

TREATMENTTREATMENT

Thrombogenical phase: HEPARINThrombogenical phase: HEPARIN FibrinolyticalFibrinolytical haemorrhagical phase:haemorrhagical phase:

Fresh plasmaFresh plasma

Concentrate of thrombocytesConcentrate of thrombocytes

+/+/-- heparinheparin

12 hemorrhagic syndromes

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