Hematology Question 8 Instructor

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.

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