Easy bruising resident survival guide

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 to the skin. 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

• Thrombotic Thrombocytopenic Purpura
• Disseminated intravascular coagulation
• Leukemia
• Severe thrombocytopenia

Other causes

• Hemophilia A
• Hemophilia B
• Scurvy
• Von Willebrand disease
• Ehlers-Danlos syndrome
• Corticosteroid use
• Anticoagulant therapy
• Idiopathic Thrombocytopenic Purpura
• Henoch-Schonlein Purpura
• Vitamin K deficiency
• Liver disease
• Systemic Lupus Erythematosus
• Glanzmann Thrombasthenia
• Bernard-Soulier syndrome

Diagnosis

The algorithm below summarises approach to the different causes of easy bruising.

References

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? Corticosteroids Heparin Warfarin Other anticoagulants Aspirin ❑ 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

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

G01

G02

G03

G04