Question 30.2

List five (5) likely causes for the following coagulation profile:

Test	Value	Normal Range
PT*	35.4 sec	(12.0 – 15.0)
INR*	3.5	(0.8 – 1.1)
APTT*	>170.0 sec	(25.0 – 37.0)
FIBRINOGEN*	0.9 G/L	(2.20 – 4.30)

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College Answer

•     DIC
•    Primary fibrinolysis
•    Dilutional coagulopathy from massive transfusion
•    Post thrombolysis
•    Snake bite

Discussion

Everything is wrong in this coags panel. Both the intrinsic and extrinsic pathways have become deranged, and the fibrinogen is depleted. The latter is a clue that some sort of consumption coagulopathy is taking place.

Again, I reproduce this table, from this chapter:

Assessment of Prolonged Clotting Times
	Normal PT	Raised PT
Normal APTT	von Willebrand's disease Platelet dysfunction Fibrinolysis disorder	Extrinsic pathway failure Warfarin therapy Vitamin K deficiency Liver disease
Raised APTT	Intrinsic pathway failure Heparin therapy von Willebrand's disease (de facto Factor 8 deficiency) Factor 8 deficiency (Haemophilia A) Factor 9 deficiency (Haemophilia B) Factor 11 deficiency (Haemophilia C, 8% of Ashkenazi Jews) Factor 12 deficiency (which is freakishly rare, and usually totally asymptomatic) Antiphospholipid antibodies	Intrinsic and extrinsic pathway failure DIC Massive transfusion Massive warfarin overdose Primary fibrinolysis Post thrombolysis Snake bite Direct thrombin inhibitor toxicity Severe liver failure

So, the differentials for this sort of pan-coagulopathy are

DIC
Massive transfusion (dilutional coagulopathy)
Massive warfarin overdose
Primary fibrinolysis
Post thrombolysis
Snake bite
Severe liver failure

References

Hunt, Beverley J. "Bleeding and coagulopathies in critical care." New England Journal of Medicine 370.9 (2014): 847-859.

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Question 30.2

College Answer

Discussion

Extrinsic pathway failure

Intrinsic pathway failure

Intrinsic and extrinsic pathway failure

References