What are the key investigations and management strategies for an elderly male presenting with painless spontaneous traumatic bruising?

Management of Painless Spontaneous Bruising in Elderly Males

In an elderly male presenting with painless spontaneous bruising, immediately investigate for anticoagulant use, obtain coagulation studies (INR, aPTT, platelet count, fibrinogen), and perform a complete blood count, as this presentation may indicate life-threatening coagulopathy requiring urgent reversal. 1, 2

Key Investigations

Initial Laboratory Assessment

• Complete blood count (CBC) to assess for anemia and thrombocytopenia 1, 3
• Coagulation panel: INR, aPTT, fibrinogen, and platelet count 1
• Blood gas analysis (arterial or venous) for baseline base deficit or lactate assessment 1
• If aPTT is prolonged: Repeat the aPTT and perform 1:1 mixing study to differentiate factor deficiency from inhibitors (acquired hemophilia presents with prolonged aPTT that does not correct with mixing) 3

Medication History

• Document all anticoagulants and antiplatelet agents (warfarin, DOACs, aspirin, NSAIDs) as these dramatically increase hemorrhage risk 2, 4
• For patients on DOACs, obtain anti-Xa levels for rivaroxaban/apixaban or specific dabigatran levels 2
• Drug interactions increase with polypharmacy, which is common in elderly patients 4

Imaging Studies

• Low threshold for CT imaging if there is any concern for internal bleeding, particularly intracranial hemorrhage in patients on anticoagulation 2
• The diagnostic yield of contrast-enhanced CT outweighs the risk of contrast-induced nephropathy given the potential dramatic effects of under-triage 1

Clinical Assessment

• Document bruise characteristics: location, size, color, and timing 5
• Nearly 90% of accidental bruises occur on extremities; bruises on neck, ears, genitalia, buttocks, or soles are highly suspicious 5
• Yellow coloration does not reliably indicate bruise age—16% of bruises were predominantly yellow within 24 hours 5
• Patients on anticoagulants and those with compromised function are more likely to have multiple bruises 5

Management Strategies

Anticoagulant Reversal (if indicated)

For Warfarin-associated bleeding:

• Administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5 mg IV vitamin K immediately 2
• Target INR <1.5 before any surgical intervention 2

For Dabigatran-associated bleeding:

• Administer idarucizumab 5 g IV 1, 2
• If idarucizumab unavailable, use 50 units/kg IV of activated prothrombin complex concentrates (APCC) 1

For Rivaroxaban/Apixaban-associated bleeding:

• Administer andexanet alfa: 400 mg IV bolus over 15 minutes followed by 480 mg infusion over 2 hours (low dose) or 800 mg over 30 minutes followed by 960 mg over 2 hours (high dose), depending on last DOAC dose 1, 2
• If andexanet alfa unavailable, use 2000 units of 4-factor PCC 1

Hemostatic Support

• Fresh frozen plasma (FFP) for factor deficiencies 4
• Platelet transfusion for thrombocytopenia 4
• DDAVP (desmopressin) for mild bleeding disorders, von Willebrand disease, or uremia-related platelet dysfunction 4

Monitoring and Observation

• Serial base deficit and lactate measurements to assess for ongoing bleeding and resuscitation adequacy 1
• Base deficit categories: mild (-3 to -5 mEq/L), moderate (-6 to -9 mEq/L), severe (<-10 mEq/L) correlate with transfusion requirements and mortality 1
• Lactate >2 mmol/L for >48 hours or base deficit <-6 mEq/L increases mortality risk four-fold in elderly patients 1

Non-Medical Management

• Avoid further trauma: Implement fall prevention strategies 6
• Medication review: Discontinue or adjust anticoagulants/antiplatelets if bleeding risk outweighs thrombotic risk 4
• Nutritional assessment: Address malnutrition which may worsen coagulopathy 7
• Functional assessment: Patients with compromised function have higher bruising rates 5

Critical Pitfalls to Avoid

• Never dismiss prolonged aPTT without investigation—less than 50% of non-hematologists repeat abnormal aPTT, potentially missing acquired hemophilia or other serious bleeding disorders 3
• Consult hematology early when coagulation studies are abnormal, particularly if aPTT does not correct with mixing studies 3
• Do not assume bruising is benign based solely on location—elderly patients on anticoagulation require thorough evaluation even with minor trauma 2, 6
• Recognize that aging itself does not cause major coagulation changes—spontaneous bruising always warrants investigation for underlying pathology 4
• Falls are the most common cause of trauma in elderly patients (80.3%)—address underlying fall risk factors 6