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

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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