Transcript Slide 1
Practical approach to a bleeding child
Peri Kamalakar,MD Director The Valerie Fund Children’s Centers For Cancer &Blood Disorders At Saint Barnabas Health Care System Associate Director, Hemophilia Center Newark Beth israel Medical Center
Practical approach to a bleeding child
OBJECTIVES: • Overview of hemostasis • Clinical approach in making a diagnosis • Review the most common bleeding conditions • Discuss the current treatment strategies
Overview of Haemostasis
INJURY Collagen Exposure VASOCONSTRICTION Serotonin Platelet Adhesion and release reaction Platelet Phospolipid Thromboxane A2 ADP Platelet aggregation Primary haemostatic plug Stable haemostatic plug Tissue Factor Coagulation Thrombin Fibrin Fibrinolysis
Overview of Haemostasis
INJURY Collagen Exposure VASOCONSTRICTION Serotonin Platelet Adhesion and release reaction Platelet Phospolipid Thromboxane A2 ADP Platelet aggregation Primary haemostatic plug Stable haemostatic plug Tissue Factor Coagulation Thrombin Fibrin Fibrinolysis
Intrinsic Pathway Extrinsic Pathway
VII
Common Pathway
II Xa
Coagulation cascade
Kinins VIIa
Ca++
Tissue Factor XII IXa Kallikrein HMW Kininogen Contact Activation Prekallikrein XIIa XIa XI
Ca++
VIIIa
Ca++
Phospholipid X V IX VIII Va
Ca++ Phospholipid
IIa XIII XIIa XIII Fibrinogen Fibrin
PRACTICAL APPROACH TO A CHILD WITH BLEEDING HISTORY • HISTORY –
HISTORY –
HISTORY >AGE OF ONSET
> SEX >FREQUENCY >LOCATION / TYPE OF BLEEDING >DURATION OF BLEEDING > MEDICATIONS > ASSOCIATED SYMPTOMS > REVIEW OF SYSTEMS
Approach to a bleeding patient
–What is the type of bleeding disorder?
Primary hemostasis – Vascular causes Platelets-Number vs.
Function Fibrin formation – clotting factors Premature clot dissolution- post clot formation
. Approach to a bleeding patient
–Is a bleeding tendency present?
Easy Bruising Mucosal bleeding Menorrhagia Surgical Hemorrhage – Procedure vs.Diathesis
Postpartum Hemorrhage Joint and Muscle bleed –Severity of trauama
. Approach to a bleeding patient
–Is the disorder Familial or Acquired?
Family history – MOTHER & OTHER FEMALE MEMBERS IN THE IMMEDIATE FAMILY – Detailed Menstrual history
• Vascular causes – First and foremost rule out infectious causes – “ Meningococcemia” Vasculitis – Henoch-Schonlein Purpura Hemangiomas- Kassalback-Merritt syndrome
• • • • • • • • • •
Petechiae and Purpura
Infectious – Meningococcemia – Rocky mountain spotted fever – Group A strep – Atypical measles – Echovirus 9, 4, 7 – Epstein-Barr virus – Coxsackie virus A9
• • • • • • • • Non-infectious – Normal platelets HSP Coagulation disorders Trauma – Low platelets ITP Leukemia
PRACTICAL APPROACH TO A CHILD WITH BLEEDING HISTORY • PHYSICAL EXAMINATION > PETICHEAE >ECHYMOSES >JOINT BLEED &DEEPSEATED HEMATOMAS > HEPATOSPLENOMEGALY >SIGNIFICANT LYMPHADENOPATHY > ACTIVE AND PLAYFUL VS. ILL LOOKING > DYSMORPHIC FEATURES > CAFÉ-AU-LAIT SPOTS >TELANGIECATIC VESSELS >HEMANGIOMAS
PRACTICAL APPROACH TO A CHILD WITH BLEEDING HISTORY • LABORATORY WORK UP P.M.D > C.B.C./PLATELET COUNT >PERIPHERAL SMEAR- MORPHOLOGY > P.T. [ Prothrombin time] > a.P.T.T. [ Activated partial thromboplastin time] ---------------------------------------------------------------- Hemophilia service - > T.T. [ Thrombin time] > Bleeding time >Platelet aggregation studies > Factor assay
Pandora’s box: coagulation test
The results are as good as the sample is.
Standards: Time from sample to test: PT 24 hours ,PTT 4 hours.
Blood/citrate ratio: 9 :1.
Bleeding disorders
• Platelets– Acquired causes much more common Thrombocytopenia more common than functional defects Inherited disorders – both number &functional defects are extremely rare
PLATELETS – NUMBER Acquired causes are most common I.T.P.
Infections CONGENITAL THROMBOCYTOPENIAS T.A.R. syndrome
• I.T.P. Most have benign &limited course Treatment options Conservative –wait &watch Aggressive Steroids IvIGG Rhogam Rituximab
PLATELETS • Functional disorders Acquired- Aspirin; Uremia Inherited – Glanzman’s Bernard-Soulier Gray platelet syndrome
von Willebrand Disease
• The most common inherited bleeding disorder • Occurs in 1% of the population • Less than 10% of patients have bleeding events due to vWD
Inheritance of Type 1 vWD
Functions of vWF
• • • Binds to platelet receptor GP Ib and to subendothelial structures such as collagen serving as bridge between platelets and subendothelium in damaged vessels Acts as bridge between adjacent platelets in vessels with high shear (arterioles) forming small platelet aggregates Binds to circulating factor VIII protecting it and prolonging FVIII t1/2 in the circulation from 2 to 8-12 hours
Symptoms of vWD
• • • • • • Easy bruisability Epistaxis or gingival bleeding Menorrhagia Post-partum hemorrhage Post-surgical bleeding Bleeding post-dental extraction
Sub types of VW Type 2 • • • M B A Qualitative variants of vWF Absence of HMW vWF multimers Same as 2A and increased affinity for platelet gp Ib Abnormal function not caused by absence of HMW multimers • Type 3 N Decreased affinity for factor VIII Complete deficiencey of vWF & Behave as Severe Hemophilia A
Treatment Guidelines in VWD
TYPE 1 2A 2B 2M 2N 3 TREATMENT DDAVP DDAVP/FVIII-VWF FVIII-VWF FVIII-VWF FVIII-VWF FVIII-VWF
DDAVP (1-desamino-8-D-arginine vasopressin) • Parenteral form: DDAVP (for IV or SC use, 0.3 ug/kg) • Highly concentrated intranasal spray form: Stimate nasal spray (150-300 ug )
Hemophilia
Hemophilia
• Caused by an absence or decreased amount of a procoagulant – • VIII -Hemophilia A affects ~ 1:5000 males • XI -Hemophilia B affects ~ 1:30000 males • XI –Hemophilia C – Rare /Ethnicity
Epidemiology
Incidence: Hemophilia A - 1:5,000 Hempohilia B – 1: 30, 000 Hemophilia A Other Hemophilia B
Inheritance
Inheritance
Woman can have hemophilia
• Lyonization of the normal X chromosome • Turner syndrome ( XO) • Father with hemophilia/ mom as a carrier • vW type 2 N ( Normandy)
• HEMOPHILIA SEVERITY LEVELS
Severe <1% activity level - Spontaneous bleeds
•
Moderate 1 to 5% activity --Trauma/surgery bleeds Occasional joint bleeds
•
Mild 5 to 30% activity Major trauma/surgery Rare joint bleeds
Factor replacement
• 1 u/kg raises FVIII levels 2% 1/2 life : 12 hrs • 1 u/kg raises FIX levels 1 % 1/2 life 20-24 hrs
Minor Bleeding Episodes
• • • • Early joint bleeds Soft tissue & muscle bleeds Nose & gum bleeding not responding to local measures Treatment of minor bleeding episodes – 40 - 50% correction – FVIII : 25 units / kg – FIX : 50 units / kg
Major Bleeding Episodes
• • • • • Advanced soft tissue & muscle bleeds Head & neck injuries Gastrointestinal bleeding Advanced joint bleeding Treatment of major bleeding episodes • 80 – 100 % correction • FVIII : 50 units / kg • FIX : 100 units / kg
Current Products
• Plasma Products: plasma-derived factor VIII concentrate • Porcine Factor: • – Use was halted due to parvovirus/retrovirus sequences discovered Recombinant products: – First Generation: Recombinate, Kogenate, Helixate – – Second Generation: Kogenate FS, Helixate FS Third Generation: Advate • DDAVP: – Causes release of factor VIII/vWF – Increased factor activity in 30-60” – For mild hemophiliacs and mild bleeding symptoms
Replacement therapy: Joint disease
• Prophylaxis –Primary –Secondary • Intensive infusion therapy • Dose escalation modified prophylaxis
Clinical Severity
Chronic Joint
Hemophilia Treatment Center Team Members • Patient / Family • Hematologist • Nurse • Social Worker • Physical Therapist • Orthopedist • Primary Care • Infectious Disease • Genetics • Pharmacy • Dental • Hepatologist
• • • • • • •
Basis for Comprehensive Care
Hematologist – Assumes overall care Musculoskeletal – Orthopedic Surgeon, Physical therapist Nursing – Coordination of home/clinic care for rapid treatment at the earliest symptoms suggestive of a bleed Dental Genetic Counseling Infectious Disease Psychosocial – social worker
Role of Hemophilia Treatment Centers
• • • • • State-of-the-art medical treatment for persons with hemophilia through out the life span Education Research Outreach Model of comprehensive care for chronic disease
The Past…
Present
…the promise of achieving your potential
Made possible by a STRONG & Dedicated Hemophilia parent association and dedicated NJHA staff