Easy bruising resident survival guide

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

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[1]. 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.[2]

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.[3][4]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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.

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

Management

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

Do's

Dont's

References

  1. "Easy Bruising and Bleeding". Am Fam Physician. 93 (4): Online. 2016. PMID 26926825.
  2. Sham RL, Francis CW (1994). "Evaluation of mild bleeding disorders and easy bruising". Blood Rev. 8 (2): 98–104. doi:10.1016/s0268-960x(05)80014-1. PMID 7950480.
  3. Harrison LB, Nash MJ, Fitzmaurice D, Thachil J (2017). "Investigating easy bruising in an adult". BMJ. 356: j251. doi:10.1136/bmj.j251. PMID 28183694.
  4. Bashawri LA, Ahmed MA (2007). "The approach to a patient with a bleeding disorder: for the primary care physician". J Family Community Med. 14 (2): 53–8. PMC 3410146. PMID 23012146.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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