H: HEME

blood

After you consider Airway, Breathing, Cardiovascular, Disability, Endo, Fluids/fertility and GI, you can consider the Heme system–which includes four components: Hemoglobin, Early platelet plug, Making coagulation factors, and Elevated dimer/reduced fibrinogen

HEMOGLOBIN: think ANEMIC to determine the cause and specific treatment besides transfusion

  • Abnormal Hgb (functional anemia): COHb, MetHb –> reverse
  • Nutritional: nutritional (iron/B12/folate), toxic-metabolic (eton, lead, hypothyroid, uraemia), aplastic –> dc toxin, replace nutrients,
  • Electrophoresis: sickle cell, thalassemia, porphyria, G6PD, spherocytosis
  • Megaspleen: sequestration –> potential splenectomy
  • Intravascular hemorrhage –> control bleeding
  • Consumption: toxic (venom, bacteria, virus, parasite), immune (AIHA, drug, fetomaternal), MAHA, macrovascular (valve) –> treat underlying

 

EARLY PLATELET PLUG: if platelet dysfunction (mucosal bleeding) think PLATELIT to determine cause and specific treatment

falsely low

  • Pseudo: clumping

functional decrease

  • Low vWF, Fg –> cryo or DDAVP
  • ASA, plavix, IIb/IIIa –> Platelet
  • Toxic: uremic, malignant

numeric decrease

  • Enlarged spleen –> potential splenectomy
  • Low marrow: leukaemia, infection, virus, toxic (chemo, etoh)
  • Immune: ITP –> steroids
  • Thrombosis: MAHA, HIT

hematology

MAKE COAGULATION FACTORS:

-PT: endogenous (liver), exogenous (coumadin) –> vitamin K, FFP

-PTT: endogenous (hemophilia, vWD)–> DDAVP/cryo (VIII-vWF); exogenous (heparin)–> protamine

 

ELEVATE DIMER, REDUCE FIRINOGEN

Elevated D-dimer does not equal PE. Consider the differential for an elevated DIMER before you order it so that you can interpret the results

  • DIC
  • Inflammation: rheumatological
  • Malignant
  • Estrogen (pregnant)
  • RBC clot: DVT/PE, hematoma, dissection

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