Easy bruising resident survival guide

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Easy bruising resident survival guide
Overview
Causes
Diagnosis
Diagnostic clues
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sanjana Nethagani, M.B.B.S.[2]

Synonyms and Keywords:

Overview

Easy bruising is the bruising of skin with minor compression or pressure. When small capillaries of the superficial skin rupture from pressure or compression, petechiae occur, sometimes ecchymosis is also seen with insignificant trauma which is a bleed in the deeper layers in the skin. A wide variety of causes lead to easy bruising, some of which are clotting and bleeding disorders, platelet dysfunction, age-related skin changes, and some forms of cancer such as leukemia.

Causes

Life threatening causes

Other causes

For a full list of causes of easy bruising, click here.

Diagnosis

The algorithm below summarises approach to the different causes of easy bruising.[1][2][3]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Detailed history:

❑ Is the bleeding over the limbs?
❑ Is there any bleeding in mucosal surfaces such as gums or oral mucosa?
❑ History of recent infections?
❑ Is there bleeding into the joints?
❑ Is there history of bruising after minor trauma in the past?
❑ Is there any associated rash?
❑ History of blood transfusions?
❑ History of bleeding after tooth extractions or surgeries
❑ Bleeding during menstrual cycle in women
❑ Drug history:
Any use of the following in the past?

Family history of bleeding?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms
❑ Bruising with minor or no trauma
Petechiae
❑ Gingival bleeding
Menorrhagia
❑ Painful bleeding into joints
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial investigations
Complete blood count with platelet count
PT/aPTT
INR
Liver function tests
Thyroid function tests
Renal function tests
Peripheral smear
Bleeding time
Platelet function analyzer

Other investigations

Von Willebrand factor levels
Factor VIII level
Factor IX level
Fibrinogen level
ADAMTS13 level
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disorders of secondary hemostasis
❑ Abnormal PT/aPTT
❑ Abnormal factor assays
❑ Abnormal fibrinogen level
 
Decreased platelet count
❑ mild: 100,000 - 150,000 per µL
❑ moderate: 50,000 to 99,000 per µL
❑ severe: <50,000 per µL (may require transfusion)
 
Disorders of platelet function
❑ Prolonged bleeding time
Thrombocytopenia
❑ Abnormal PFA-100
❑ Abnormal Von Willebrand factor assay
❑ Abnormal Ristocetin induced platelet agglutination
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clotting factor disorders
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inherited
 
Acquired
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Von Willebrand disease
* Abnormal Von Willebrand factor assay
* Abnormal Glycoprotein 1b assay
* Hypoactive agglutination on ristocetin induced platelet aggregation
* Low factor VIII levels
* Prolonged PTT
Glanzmann's thrombasthenia
* Abnormal platelet aggregation assays
* Monoclonal antibody testing
* Flow cytometry
Bernard-Soulier syndrome
* Giant platelets on peripheral smear
* Abnormal ristocetin aggregation
Oculocutaneous albinism/Hermansky-Pudlak syndrome
* Absent dense bodies on electron microscopy of platelets
* Abnormal platelet aggregation assays
Chédiak-Higashi syndrome
* Abnormal platelet aggregation assays
* Defective platelet storage granules
Isolated dense granule deficiency
* Defective platelet aggregation
* Decreased ADP/ATP ratio
 
Uremia
❑ Acquired Von Willebrand disease
Aspirin and other NSAIDs
Glycoprotein IIb/IIIa inhibitors
Cardiopulmonary bypass
Dysproteinemia
❑ Myeloproliferative disorders
Cardiopulmonary bypass
❑ Infections such as Dengue fever or Hepatitis C
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemophilia A
* Normal PT
* Prolonged PTT
* Abnormally low Factor VIII
 
Hemophilia B
* Abnormally low Factor IX
* Normal PT
* Prolonged PTT
 
Hemophilia C
* Prolonged aPTT
* Abnormally low Factor XI
 
 
Low/undetectable fibrinogen
* Afibrinogenemia
* Hypofibrinogenemia
* Hypodysfibrinogenemia
 
 
 
 
 
 
 
 
 
No abnormalities detected in initial analysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider other diagnoses
❑ Senile purpura
Aplastic anemia
❑ Long term corticosteroid use
Scurvy
Vitamin K deficiency
❑ Domestic abuse
Leukemia
Meningococcal infection
Ehlers-Danlos syndrome
Alpha 2-antiplasmin deficiency
Plasminogen activator inhibitor-1 deficiency
Factor XIII deficiency
Lupus anticoagulant
Antiphospholipid syndrome
ITP
TTP/HUS
❑ Liver disease

Diagnostic clues

Shown below is a table summarizing different findings in easy bruising and their interpretation.[4]

Associated conditions Platelet count Bleeding time RIPA Peripheral smear PT aPTT Fibrinogen Thrombin time Factor assays
Thrombocytopenia Normal Few platelets on smear Normal Normal Normal Normal Normal
Von Willebrand disease Normal Hypoactive agglutination Normal Normal Normal/ slightly prolonged Normal Normal Factor VIII
Bernard-Soulier syndrome Hypoactive agglutination & normal ristocetin cofactor assay Giant platelets Normal Normal Normal Normal Normal
Glanzmann's thrombasthenia Normal Clumping with ristocetin Normal Normal Normal Normal Normal Normal
Hemophilia A, Hemophilia B, use of Heparin, Antiphospholipid syndrome or Lupus anticoagulant Normal Normal Normal Normal Normal Normal Normal Factor VIII, IX, XI or XII
Factor VII deficiency, early in the course of treatment with warfarin, initial stages of liver disease Normal Normal Normal Normal Normal Normal Normal Factor VII
Factor II, V or X deficiency, oral anticoagulant use, Vitamin K deficiency, chronic liver disease Normal Normal Normal Normal Normal Normal ↓ Factor II, V & X
Chronic liver disease, hyperfibrinolysis, heparin use Normal Normal Normal Normal Normal Normal
Splenomegaly, chemotherapy, immune mediated destruction Normal Normal Normal Normal Normal Normal Normal Normal/↓
Multiple transfusions, massive blood loss Normal Normal Normal
Disseminated intravascular coagulation Normal Shistocytes Normal/↓

Treatment

The goal of treatment of easy bruising is to identify and treat the underlying disorder. [5]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Categorize the bruises and other symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild bruises
 
 
 
 
 
 
Moderate to severe bruises and other accompanying symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Rest
❑ Ice
❑ Elevation
❑ Compression
NSAIDs for pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thrombocytopenia
Platelet transfusion after ruling out other conditions
 
 
 
 
 
 
 
Disorders of platelet function
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
von Willebrand disease
Desmopressin releases weibel-palade bodies from endothelial cells
von Willebrand factor concentrate
Tranexamic acid
Estrogen containing oral contraceptive pills for women who are affected
❑ Human-derived medium purity Factor VIII concentrate
Glanzmann's thrombasthenia
❑ Avoid aspirin and NSAIDs
Tranexamic acid or Aminocaproic acid
Oral contraceptive pills to decrease menstrual bleeding
❑ Recombinant Factor VIIa
Bernard-Soulier syndrome
Platelet transfusion
Tranexamic acid
❑ Avoid aspirin

Acquired disorders of platelet function
Uremic platelet dysfunction
Erythropoietin can be used for prevention and treatment
Cryoprecipitate can be used in bleeding diathesis
Desmopressin is the agent used most commonly in active bleeding
Estrogen acts by decreasing L-Arginine which in turn decreases Nitric Oxide which sees an increased production in uremia
Drugs such as aspirin
❑ Discontinuation of drug
DDAVP for mild bleeding
Platelet transfusion for major bleeding
Cardiopulmonary bypass
Heparin
❑ Serine protease inhibitors such as aprotinin
❑ Decreasing platelet adhesiveness with Nitric oxide
Dypyridamole
Antiplatelet antibodies
Corticosteroids
Rituximab
Splenectomy
Intravenous immunoglobulin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Disorders of secondary hemostasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemophilia A
❑ Recombinant Factor VIII
Plasma transfusions
Desmopressin for mild bleeds
 
Hemophilia B
Factor IX infusion
Blood or plasma transfusions in severe bleeding
❑ Avoid NSAIDs
Tranexamic acid should be given before any procedure
 
Hemophilia C
Fresh frozen plasma
❑ Recombinant Factor XI
❑ Cyclokapron is used as a preventative measure and treatment
 
 
Disorders of fibrinogen
Afibrinogenemia and hypofibrinogenemia- plasma derived fibrinogen concentrate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No abnormalities detected on initial screen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider other diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Senile purpura
❑ Topical retinoids may be of some benefit
 
 
Infections
Dengue fever
* Oral rehydration therapy
* Blood transfusion in severe cases
Meningococcal infection
* Third generation cephalosporins
* Hydration
 
Aplastic anemia
Bone marrow transplant
Antithymocyte globulin
Chemotherapy in some cases
 
 
Vitamin deficiencies
Scurvy
* Vitamin C supplementation
Vitamin K deficiency
* Phytonadione
* Vitamin K by IV infusion for bleeding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lupus anticoagulant
* LMWH
* Warfairn
Antiphospholipid syndrome
* Aspirin(preferred in pregnancy)
*Warfarin
* LMWH
Ehlers-Danlos syndrome
* There is no known cure
* Physiotherapy and Occupational therapy
Vitamin C may help with bruising
Leukemia
* Chemotherapy
Plasminogen activator inhibitor-1 deficiency
* Tranexamic acid
* Aminocaproic acid
Alpha-2 antiplasmin deficiency
* Tranexamic acid
* Aminocaproic acid
Factor XIII deficiency
* Factor XIII concentrate
Liver disease
* Eltrombopag
* Romiplostim
* Platelet transfusions if necessary
Domestic abuse must be considered in any patient with multiple bruises after ruling out other pathologies

Do's

Dont's

  • Avoid contact sports.
  • Avoid repeated pricks for investigations/ blood sample collection in patients with hemophilia or other bleeding disorders.
  • Transfusion is contraindicated in TTP.
  • Do not prescribe aspirin or other NSAIDs during phases of active bleeding.

References

  1. Srámek A, Eikenboom JC, Briët E, Vandenbroucke JP, Rosendaal FR (1995). "Usefulness of patient interview in bleeding disorders". Arch Intern Med. 155 (13): 1409–15. PMID 7794090.
  2. Wahlberg T, Blombäck M, Hall P, Axelsson G (1980). "Application of indicators, predictors and diagnostic indices in coagulation disorders. I. Evaluation of a self-administered questionnaire with binary questions". Methods Inf Med. 19 (4): 194–200. PMID 7432180.
  3. Mauer, A. C.; Khazanov, N. A.; Levenkova, N.; Tian, S.; Barbour, E. M.; Khalida, C.; Tobin, J. N.; Coller, B. S. (2011). "Impact of sex, age, race, ethnicity and aspirin use on bleeding symptoms in healthy adults". Journal of Thrombosis and Haemostasis. 9 (1): 100–108. doi:10.1111/j.1538-7836.2010.04105.x. ISSN 1538-7933.
  4. Schuurman R, Jacobs M, van Strien A, van der Noordaa J, Sol C (1992). "Analysis of splice sites in the early region of bovine polyomavirus: evidence for a unique pattern of large T mRNA splicing". J Gen Virol. 73 ( Pt 11): 2879–86. doi:10.1099/0022-1317-73-11-2879. PMID 1279101.
  5. Valente, Maria J.; Abramson, Neil (2006). "Easy Bruisability". Southern Medical Journal. 99 (4): 366–370. doi:10.1097/01.smj.0000209237.73616.33. ISSN 0038-4348.