A 30-year-old lawyer presents to the Emergency Department with a short history of easy bruising and frank haematuria. On examination, he has widespread bruises but there is little else to find. Prior to his blood work returning, he sustains a loss of consciousness and is transferred to the MSICU. A CT head shows a 3cm subdural hemorrhage. There was no past medical history or family history suggestive of a bleeding disorder.
His blood tests show:
| Test | Patient | Reference Range |
| PT | >120s | 11-14s |
| APTT | >120s | 23-35s |
| Fibrinogen (Clauss) | 3.2g/L | 1.5-4.0g/L |
| Thrombin Time | 13s | 10-13s |
| Hemoglobin | 104g/L | 130-180g/L |
| Platelets | 156 x 109/L | 150-400 x 109/L |
Is this disseminated intravascular coagulation?
No – the fibrinogen is normal and both the PT and PTT are elevated, indicating a deficiency in the common pathway.
What additional tests should be done immediately to assess the differential diagnosis?
A 50:50 mixing study.
A 50:50 mix is completed, showing the following:
| Test | Patient | Reference Range |
| PT pre 50:50 | >120s | 11-14s |
| APTT pre 50:50 | >120s | 23-35s |
| PT control | 11s | 11-14s |
| PT post 50:50 | 13s | 11-14s |
| PTT control | 31s | 23-35s |
| PTT post 50:50 | 34 | 23-35s |
Factor levels are requested for this patient, showing a reduction in all factor levels except factors 8, 11, and 12. His factors 2, 7, 9, and 10, and protein C and S levels, are undetectable. What treatment should be given immediately?
This patient in fact overdosed on warfarin. Vitamin K should be given immediately with a prothrombin complex concentrate to reverse his bleed and neurosurgical consultation.
