The Bleeding Patient

Most bleeding that is seen in the ED is normal—the result of local wounds, lacerations, or other structural lesions. The majority occurs in patients with normal hemostasis. With careful attention to the history and physical findings, patients with pathologic bleeding often can be readily identified. Generally speaking, patients who manifest spontaneous bleeding from multiple sites, bleeding from untraumatized sites, delayed bleeding several hours after trauma, and bleeding into deep tissues or joints should be considered to possibly have a bleeding disorder.

Important historical data for the presence of a congenital bleeding disorder include the presence or absence of unusual or abnormal bleeding in the patient and other family members and the possible occurrence of excessive bleeding after dental extractions, surgical procedures, or trauma. Many patients with abnormal bleeding have an acquired disorder. Questioning about liver disease and drug use (particularly ethanol, aspirin, nonsteroidal anti-inflammatory drugs, warfarin, antibiotics, and other aspirin-containing products) may be helpful.

The site(s) of bleeding may provide an indication of the hemostatic abnormality. Mucocutaneous bleeding, including petechiae, ecchymoses, epistaxis, gastrointestinal, genitourinary, or heavy menstrual bleeding is characteristic of qualitative or quantitative platelet disorders. Purpura often are associated with thrombocytopenia and commonly indicate systemic illness. Bleeding into joints and potential spaces, such as between fascial planes and into the retroperitoneum, as well as delayed bleeding, is most commonly associated with coagulation factor deficiencies. Patients who demonstrate both mucocutaneous bleeding and bleeding in deep spaces often have disorders such as disseminated intravascular coagulation, where both platelet abnormalities and coagulation factor abnormalities are present.

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