- Assessment of the patient with a bleeding diathesis requires careful history-taking and bedside evaluation and comprehensive baseline coagulation testing.
- Uncomplicated vascular injury related to trauma or surgery should be eliminated as the primary cause of bleeding before the possibility of a coagulopathy is invoked.
- Consideration of coagulation abnormalities should include vascular disorders, platelet problems, impairment of the fibrin generation cascade, and excessive fibrinolytic activity.
- Disseminated intravascular coagulation may present with either thrombotic or bleeding problems. Awareness of the possibility of this diagnosis and prompt, appropriate laboratory confirmation may improve treatment selection and outcome.
- Invasive procedures in critically ill patients with coagulopathies need to be performed with special caution to prevent complications. Some guidelines are presented.
Accurate diagnosis of the mechanism of a bleeding disorder is based on careful history-taking and bedside evaluation of the patient, coupled with appropriate confirmatory laboratory testing.1 Information obtainable from the patient or others about a pre-existing congenital or acquired bleeding diathesis, medications being taken, recent surgery or pregnancy, and underlying disturbed organ function (e.g., hepatic or renal insufficiency) will facilitate the diagnostic process and provide the basis for directing empirical urgent therapy should it be necessary before laboratory testing can be completed.
Careful physical examination may clarify whether observed bleeding is strictly a local problem, i.e., limited to one site and not out of proportion in severity to that expected from an observed injury or fixed lesion, or is due to a systemic bleeding diathesis, which should be suspected if multiple bleeding or bruising sites are present and cannot be accounted for by the extent or severity of known trauma. In some patients with a single mechanism of systemic coagulopathy, it may be possible to distinguish a vascular or platelet disorder, which is characterized by immediate bleeding (prolonged, continued bleeding after onset and dominant petechial/mucosal manifestations), from a problem of fibrin generation (a cascade disorder) or of fibrinolysis, which is typified by delayed bleeding (rebleeding after initial hemostasis and prominent ecchymoses or deep muscle and joint hemorrhage). Complex coagulopathies, such as disseminated intravascular coagulopathy (DIC), may have features of both categories. The presence of findings such as splenomegaly or telangiectases also may be helpful clues.
Several generalizations based on data from the history and physical examination may help in directing the workup and treatment of bleeding problems. The first consideration in the evaluation of a bleeding patient—before a coagulopathy is invoked as a contributing cause—is to exclude uncomplicated vascular injury (related to trauma or surgery) that would be amenable to surgical hemostasis techniques. Second, brisk bleeding is almost never due to spontaneous hemorrhage caused by a coagulopathy alone. Third, clinically significant bleeding often is the result of the coexistence of trauma or a potential bleeding lesion (e.g., a peptic ulcer) with a coagulopathy that may antedate the lesion or may develop while the lesion is present. Fourth, initial and follow-up laboratory screening of critically ill patients for the presence of a potential ...