Lee Adrienne
Departments of Medicine, Cumming School of Medicine, University of Calgary and the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, 1403-29th Street NW, Calgary, AB T2N 2T9, Canada.
Transfus Apher Sci. 2019 Oct;58(5):553-562. doi: 10.1016/j.transci.2019.08.003. Epub 2019 Aug 6.
Emergency department (ED) physicians are often the first point of contact for patients who present with bleeding symptoms. Work up and management of bleeding in the emergency room can be a daunting task as it requires: (1) accurate diagnosis of the bleeding cause, of which there is long list of common and rare etiologies (2); appropriate investigations and interpretation of the results; and (3) timely management of bleeding symptoms to prevent limb- or life-threatening complications. Crucial to the management of a bleeding patient is a thorough yet focused history exploring bleeding symptoms, medications/drugs (anticoagulants, antiplatelets), mechanism of trauma/injury, personal and family history of diagnosed bleeding disorders or bleeding symptoms and recognizing acuity and severity of bleeding that requires immediate intervention. Physical examination should focus on signs of mucocutaneous versus deep tissue or joint bleeding and assessing for structural lesions that may contribute to bleeding symptoms in patients with known bleeding diathesis. In patients with diagnosed bleeding disorders, emergency care cards will usually outline the initial treatment (e.g. clotting factor replacement, DDAVP) which should be administered before pursuing investigations/imaging studies. Special attention must be paid to the patient with recurrent or unexplained bleeding, or unexplained coagulation studies. There should be a low threshold to consult hematology in these cases and involvement of hematology early in managing patients with bleeding disorders to improve outcomes. This paper is directed toward emergency physicians, pediatricians, and general internists and will highlight key concepts in the primary care and work up of diagnosed and undiagnosed bleeding disorders requiring urgent treatment.
急诊科医生通常是出现出血症状患者的首诊医生。在急诊室对出血进行检查和处理是一项艰巨的任务，因为它需要：（1）准确诊断出血原因，常见和罕见病因众多；（2）进行适当的检查并解读结果；（3）及时处理出血症状，以预防肢体或危及生命的并发症。对于出血患者的处理，关键在于全面且有重点地询问病史，了解出血症状、药物/毒品（抗凝剂、抗血小板药物）、创伤/损伤机制、个人及家族诊断出血性疾病或出血症状的病史，以及识别需要立即干预的出血的紧急程度和严重程度。体格检查应重点关注黏膜皮肤出血与深部组织或关节出血的体征，以及评估可能导致已知出血素质患者出现出血症状的结构病变。对于已诊断出血性疾病的患者，急救卡通常会列出初始治疗方法（如凝血因子替代、去氨加压素），应在进行检查/影像学研究之前给予。对于反复出血或不明原因出血、凝血检查不明原因的患者，必须给予特别关注。在这些情况下，应降低咨询血液科的门槛，并在出血性疾病患者的管理早期就让血液科参与，以改善治疗效果。本文针对急诊科医生、儿科医生和普通内科医生，将重点介绍需要紧急治疗的已诊断和未诊断出血性疾病的初级护理及检查中的关键概念。
