• Cushing’s syndrome Medications are the most common acquired cause of bleeding. 5. Evaluation of Bleeding Patient 33 ! VWD is the most common congenital cause of bleeding. Medications are the most common acquired cause of bleeding. A T T E N T I O N ! A bleeding time is no longer recommended for the investigation of bleeding disorders. A T T E N T I O N 34 5. APPROACH TO THE EVALUATION OF THE BLEEDING PATIENT 5. Evaluation of Bleeding Patient 35 Epistaxis No or trivial (≤ 5 per year) > 5 per year or more than 10 minutes CLINICALSITUATION -1 0 1 Consultation only Packing or cauterization or antifibrinolytic 2 3 Blood transfusion or replacement therapy or desmopressin Cutaneous No or trivial (≤ 1 cm) > 1 cm and no trauma Consultation only Bleeding from minor wounds No or trivial (≤ 5 per year) > 5 per year or more than 5 minutes Consultation only Surgical hemostasis Blood transfusion or replacement therapy or desmopressin Oral cavity No Referred, no consultation Consultation only Surgical hemostasis or antifibrinolytic Blood transfusion or replacement therapy or desmopressin Gastrointestinal bleeding No Associated with ulcer, portal hypertension, hemorrhoids, angiodysplasia Spontaneous Surgical hemostasis, blood transfusion, replacement therapy, desmopressin, antifibrinolytic Tooth extraction None done or no bleeding in 1 extraction No bleeding in at least 2 extractions Reported, no consultation Consultation only Resuturing or packing Blood transfusion or replacement therapy or desmopressin Surgery None done or no bleeding in 1 surgery No bleeding in at least 2 surgeries Reported, no consultation Consultation only Surgical hemostasis or antifibrinolytic Blood transfusion or replacement therapy or desmopressin Menorrhagia No Consultation only Antifibrinolytics, oral contraceptive pill use Dilation & curettage, iron therapy, ablation Blood transfusion or replacement therapy or desmopressin Postpartum hemorrhage None done or no bleeding in 1 delivery No bleeding in at least 2 deliveries Consultation only Dilation & curettage, iron therapy, antifibrinolytics Blood transfusion or replacement therapy or desmopressin Hysterectomy Muscle hematomas Never Post trauma, no therapy Spontaneous, no therapy Spontaneous or traumatic, requiring desmopressin or replacement therapy Spontaneous or traumatic, requiring surgical intervention or blood transfusion Hemarthrosis Never Post trauma, no therapy Spontaneous, no therapy Spontaneous or traumatic, requiring desmopressin or replacement therapy Spontaneous or traumatic, requiring surgical intervention or blood transfusion Central nervous system bleeding Never Subdural, any intervention Intracerebral, any intervention 4 Here is an example of a bleeding assessment tool validated for the assessment of VWD and platelet function disorders: The Condensed MCMDM-1 VWD Bleeding Questionnaire has been validated for VWD and PFD ▲ The bleeding score is determined by scoring the worst episode for each symptom (each row) and then summing all of the rows together. ▲ “Consultation only” refers to a patient consulting a medical professional (doctor, nurse, dentist) because of a bleeding symptom where no treatment was given. Other ▲ For VWD, a bleeding score ≥ 4 has a sensitivity = 100%, specificity = 87%, positive predictive value (PPV) = 20%, negative predictive value (NPV) = 100%. (Bowman, 2008) ▲ For PFD, a bleeding score ≥ 4 has a sensitivity = 86%, specificity = 65%, PPV = 50% and NPV = 92%. (James, 2011) Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies Chrysoula Papageorgiou, MD1 , Georges Jourdi, MD, PhD2,3, Eusebe Adjambri, MD4 , Amanda Walborn, PhD5 , Priya Patel, PhD5 , Jawed Fareed, PhD5 , Ismail Elalamy, MD, PhD6,7, Debra Hoppensteadt, PhD5 , and Grigoris T. Gerotziafas, MD, PhD6,7 Abstract Disseminated intravascular coagulation (DIC) is an acquired clinicobiological syndrome characterized by widespread activation of coagulation leading to fibrin deposition in the vasculature, organ dysfunction, consumption of clotting factors and platelets, and life-threatening hemorrhage.