What is the recommended workup and management for patients presenting with significant bruising after bloodwork?

Workup and Management of Significant Bruising After Bloodwork

The recommended workup for patients presenting with significant bruising after bloodwork should include a complete blood count, peripheral blood smear, prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level to identify potential underlying bleeding disorders. 1

Initial Assessment

History

• Duration and extent of bruising
• Family history of bleeding disorders
• Medication review (anticoagulants, antiplatelet agents)
• Previous bleeding episodes (surgical, dental, trauma-related)
• Associated symptoms (joint bleeding, mucosal bleeding)
• Use of the International Society on Thrombosis and Hemostasis bleeding assessment tool to quantify bleeding severity 2

Physical Examination

• Document size, location, and appearance of bruising
• Check for additional bruising elsewhere on the body
• Assess for mucocutaneous bleeding (suggests platelet dysfunction)
• Look for hemarthroses or hematomas (more common in coagulopathy)

Laboratory Evaluation

First-line Testing

1. Complete blood count (CBC) with platelet count
2. Peripheral blood smear
3. Prothrombin time (PT) and International Normalized Ratio (INR)
4. Activated partial thromboplastin time (aPTT)
5. Fibrinogen level

Interpretation of Results

• Normal PT and aPTT: Consider platelet disorder (most commonly von Willebrand disease) 1
• Normal PT with prolonged aPTT: Indicates deficit in the intrinsic pathway; perform mixing study 2
• Prolonged PT with normal aPTT: Consider vitamin K deficiency; perform vitamin K challenge 2
• Both PT and aPTT prolonged: Evaluate for liver failure or disseminated intravascular coagulation 2

Management Algorithm

For Normal Laboratory Results

1. Reassurance if isolated incident with normal labs
2. Consider local factors:
   • Technique of venipuncture
   • Pressure applied after blood draw
   • Fragile vessels (especially in elderly)
   • Skin integrity

For Abnormal Laboratory Results

1. Platelet disorders:

   • If platelet count <75 × 10^9/L, consider platelet transfusion 3
   • For functional platelet disorders with normal count, consider hematology referral

2. Coagulation disorders:

   • For PT/aPTT >1.5 times normal, consider fresh frozen plasma (15 ml/kg) 3
   • For fibrinogen <1 g/L, administer fibrinogen concentrate or cryoprecipitate 3

3. For severe bleeding:

   • Apply direct pressure to bleeding site
   • Consider hemostatic dressings
   • Implement institutional major hemorrhage protocol if bleeding is massive 3

Special Considerations

Easy Bruising Syndrome

• Predominantly affects women
• May present with normal platelet count and coagulation studies
• Can be categorized into two types:
  • Type I: Normal to supranormal platelet function
  • Type II: Abnormal platelet function (impaired aggregation) 4

Thyroid Disease Association

• Elevated platelet IgG levels may be associated with easy bruising in patients with Graves' disease or Hashimoto's thyroiditis 5

When to Refer to Hematology

• Abnormal laboratory results despite initial management
• Strong family history of bleeding disorders
• Recurrent significant bruising despite normal initial workup
• Suspicion of rare bleeding disorders not detected by standard tests 1

Prevention of Future Bruising

• Ensure adequate pressure is applied after venipuncture (minimum 2-3 minutes)
• Use smaller gauge needles when appropriate
• Consider alternative sites for blood draws in patients with recurrent bruising
• Apply cold compresses immediately after blood draw if bruising is anticipated

Remember that while most cases of bruising after bloodwork are benign, systematic evaluation is essential to rule out underlying bleeding disorders that may require specific management.