Oozing from a Venepuncture Site
OVERVIEW
- An approach to the patient with persistent bleeding from a venepuncture site
DIFFERENTIAL DIAGNOSIS
- vascular defects
— congenital (connective tissue disorders) or acquired (senile purpura, infection, steroids, Henoch-Schönlein Purpura) - platelet disorders
— decreased production (bone marrow disease) , increased destruction (immune, non-immune), poor function (renal failure, post CPB, drugs), sequestration (hypersplenism) - coagulation disorders
— congenital (haemophilia, vWB disease) or acquired (anti-coagulants, DIC, liver disease, thrombolysis) - error
— inadvertent arterial puncture
APPROACH
- resuscitate, diagnose and treat cause
ASSESSMENT
History
- pre-existing bleeding tendency
- drugs
- ETOH
- liver disease
- sepsis
- PMHx and FHx
- other places patient is bleeding from
Examination
- focused examination relevant to above
- haemodynamic stability
- bleeding sites (e.g. mucosae, wounds, haemarthroses, urine, PR, trauma sites (SCALPer mnemonic))
- evidence of systemic disease (e.g. CTD, hypersplenism, liver disease, sepsis, Cushing’s)
Investigations
- FBC
- blood film
- Coags — PT, APTT, Thrombin time, fibrinogen
- D-dimer
- bleeding time: tests platelet function, normal < 10mins (rarely done now)
- PFA-100 (platelet function test)
- factors levels: VIII (haemophilia A), IX (haemophilia B), vWF
- ADAMTS autoantibodies for TTP
- valid group and hold / cross-match
MANAGEMENT
- proportional to bleeding
- hemostatic resuscitation with appropriate blood products if needed
- control bleeding (e.g. direct pressure, elevation)
- treat underlying cause and stop perpetuating factors
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC