Managing the bleeding patient.

1. George A Fritsma, MS MT(ASCP)[⇑][1] 1. is in the Department of Pathology, UAB Coagulation Service Coordinator at the University of Alabama at Birmingham, Birmingham AL 1. Address for correspondence: George A Fritsma MS MT (ASCP), Department of Pathology, 619 South 19th Street, West Pavilion, P230, University of Alabama at Birmingham, Birmingham AL 35249. gfritsma{at}path.uab.edu. Website: The reader will be able to: 1. distinguish between anatomic and systemic hemorrhage. 2. distinguish between acquired and congenital hemorrhage. 3. select hemostatic laboratory tests that may be used to establish the presence of a hemostatic disorder. 4. identify hemostatic laboratory tests for use in pinpointing the cause of hemorrhage. 5. interpret the laboratory test profile results used to establish the presence of disseminated intravascular coagulation. 6. interpret the laboratory test profile results used to establish the presence of von Willebrand disease. 7. select single coagulation factor assays. 8. describe how to perform and interpret mixing studies. 9. determine the presence of a coagulation inhibitor. 10. select the appropriate coagulation factor concentrate therapy to treat hemorrhagic disorders. 11. calculate the correct dosage of coagulation factor concentrate to appropriately treat hemorrhagic disorders. 12. assess the dosage adequacy of the coagulation factor concentrate used to treat hemorrhagic disorders. 13. detail the selection and dosage of factor concentrates for von Willebrand disease, hemophilia, and hemophilia with the presence of an inhibitor. The acute care hemostasis laboratory must be equipped to manage both acute and chronic hemorrhage. Hemorrhage is defined as bleeding that can be arrested only by special interventions such as pressure, elevation, ice, cauterization, ligation, or therapy.1 Therapy may include non-biologic drugs such as DDAVP and Amicar, and coagulation concentrates in various forms. Hemorrhage may be local or general, anatomic or systemic, acquired or congenital . To establish the cause for a hemorrhagic event, the clinician first completes a history and physical examination, and then follows up with diagnostic laboratory tests.2 LOCAL VERSUS GENERAL HEMORRHAGE Most bleeding is local. Hemorrhage from a single location signals a trauma, tissue necrosis, or a blood vessel defect. A surgical site may bleed because of an inadequately ligated or cauterized vessel. Local bleeding seldom implies a coagulopathy. Bleeding is classified as general when it is excessive or when it originates from two or more sites (Table 1). Menorrhagia, hematemesis, epistaxis, bleeding from the gums, or bleeds into body cavities are signs of a hemostatic deficiency. Whenever such a coagulopathy is suspected, a careful workup involving hemostasis laboratory tests is essential.3,4 ACQUIRED VERSUS CONGENITAL HEMORRHAGIC DISORDERS Bleeding that first occurs in adulthood, is associated with a specific disorder (Table 2), and is not seen in kindred, implies an acquired hemorrhagic condition. When an adult patient presents with general hemorrhage, the physician first looks for an underlying disease, and then orders a hemostasis laboratory test profile.5 Congenital coagulopathies are uncommon, occurring in approximately one in 800 individuals,… ABBREVIATIONS: PT = prothrombin time; PTT = partial thromboplastin time. The reader will be able to: 1. distinguish between anatomic and systemic hemorrhage. 2. distinguish between acquired and congenital hemorrhage. 3. select hemostatic laboratory tests that may be used to establish the presence of a hemostatic disorder. 4. identify hemostatic laboratory tests for use in pinpointing the cause of hemorrhage. 5. interpret the laboratory test profile results used to establish the presence of disseminated intravascular coagulation. 6. interpret the laboratory test profile results used to establish the presence of von Willebrand disease. 7. select single coagulation factor assays. 8. describe how to perform and interpret mixing studies. 9. determine the presence of a coagulation inhibitor. 10. select the appropriate coagulation factor concentrate therapy to treat hemorrhagic disorders. 11. calculate the correct dosage of coagulation factor concentrate to appropriately treat hemorrhagic disorders. 12. assess the dosage adequacy of the coagulation factor concentrate used to treat hemorrhagic disorders. 13. detail the selection and dosage of factor concentrates for von Willebrand disease, hemophilia, and hemophilia with the presence of an inhibitor. [1]: #corresp-1