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.