From the Guidelines
The initial evaluation of a patient with petechiae on hands should begin with a thorough history and physical examination, focusing on medication use, recent infections, and bleeding symptoms, as recommended by the American Society of Hematology guidelines 1. When evaluating a patient with petechiae, it is essential to consider the severity of bleeding and the presence of any underlying conditions.
- A complete blood count with platelet count is crucial in determining the cause of petechiae, as thrombocytopenia can be a significant concern.
- A peripheral blood smear can help identify any abnormalities in blood cells, while coagulation studies (PT, PTT, fibrinogen) can assess the patient's coagulation status.
- Vital signs should be assessed immediately, as petechiae with hemodynamic instability may indicate serious conditions like sepsis or severe thrombocytopenia.
- If the patient is a child with no bleeding or mild bleeding, observation alone may be sufficient, regardless of platelet count, as suggested by the American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia 1. However, if the patient develops an episode of bleeding, such as epistaxis, treatment should be initiated based on the severity of the bleeding.
- Laboratory testing, including a complete blood count, peripheral blood smear, coagulation studies, and basic metabolic panel, should be performed to determine the underlying cause of petechiae.
- Management depends on the underlying cause, but any life-threatening conditions should be addressed first, and treatment may include platelet transfusion, corticosteroids, or discontinuation of offending medications.
From the Research
Initial Evaluation for Petechiae
The initial evaluation for a patient presenting with petechiae involves a combination of clinical assessment, laboratory tests, and physical examination.
- A complete blood cell count, platelet count, and evaluation of a peripheral blood sample are essential routine screening tests 2.
- Prothrombin time and activated partial thromboplastin time are also crucial in determining the cause of bleeding or clotting disorders 2, 3.
- A blood smear scan, examination, and review can provide valuable information about the patient's hematologic condition, including verification of automated hematology results and determination of the need for a manual differential leukocyte count 4.
Laboratory Tests
Laboratory tests play a vital role in the evaluation of petechiae.
- A prolonged partial thromboplastin time may indicate a hemophiliac state or other clotting factor deficiencies 3, 5.
- A low platelet count can suggest peripheral destruction of platelets, immunothrombocytopenia, or bone marrow production abnormalities 3.
- Prothrombin time and thrombin time can help identify abnormalities in vitamin K-dependent clotting factors or factor V 3.
Clinical Presentation and Management
Patients with petechiae may present with spontaneous bleeding, jaundice, or purpura.
- Initial management involves prompt recognition of hematologic emergencies and initiation of appropriate treatment, such as clotting factor replacement for hereditary disorders 6.
- Severe thrombocytopenia, disseminated intravascular coagulation, and trauma coagulopathy require unique treatments and may necessitate emergent referral to a hematologic specialist 6.