FRCPath Haem Part 1 EMQs- Haemostasis 92 and 93

Theme

For each clinical scenario, select the single most appropriate treatment from the option list below. Each option may be used once, more than once, or not at all.

Options

A. Prothrombin Complex Concentrate (PCC)

B. Recombinant activated factor VII (NovoSeven®)

C. FEIBA® (Activated Prothrombin Complex Concentrate)

D. Fresh Frozen Plasma (FFP)

E. Vitamin K

F. Obizur® (Recombinant Porcine FVIII) and Steroids

G. Voncento® (VWF/FVIII concentrate)

H. Factor VIII concentrate

I. Cryoprecipitate

J. Von Willebrand factor concentrate

K. Platelet transfusion

L. Tranexamic acid

M. Obizur® (Recombinant Porcine FVIII)

Question 1

A 74-year-old man with atrial fibrillation is admitted following a fall. CT brain demonstrates a large acute subdural haematoma with midline shift. He is taking warfarin and his INR is 5.8. Neurosurgeons plan emergency decompression within 1 hour. The blood bank has sufficient blood products available. Immediate correction of coagulopathy is required.

Most appropriate treatment?

Question 2

A 69-year-old woman develops haematuria three days after commencing broad-spectrum antibiotics for cholangitis. She has been receiving warfarin for a mechanical mitral valve. INR is 8.5. She is haemodynamically stable and there is no life-threatening bleeding. Warfarin is withheld.

Most appropriate treatment?

Question 3

A 23-year-old man with severe haemophilia A develops a painful swollen knee after a football injury. Baseline FVIII <1%. He has never developed inhibitors and current status is negative as well. Joint aspiration is not required.

Most appropriate treatment?

Question 4

A 31-year-old man with severe haemophilia A presents with a spontaneous iliopsoas bleed. He is known to have a high-titre FVIII inhibitor (>20 BU). Previous treatment with FVIII concentrate produced no increment in FVIII levels.

Most appropriate treatment?

Question 5

A 76-year-old woman presents with rapidly enlarging thigh and retroperitoneal haematomas. Laboratory investigations show:

• APTT 110 seconds

• PT normal

• Mixing study fails to correct

• FVIII activity <1%

• FVIII inhibitor 80 BU

She has no previous personal or family history of bleeding.

Most appropriate treatment?

Question 6

A 54-year-old man with decompensated liver cirrhosis develops diffuse bleeding from a central venous catheter insertion site. PT and APTT are markedly prolonged. Fibrinogen level is 0.7 g/L.

Most appropriate treatment?

Question 7

A 16-year-old girl with type 3 von Willebrand disease presents with severe menorrhagia causing symptomatic anaemia. Previous desmopressin trials were ineffective.

Most appropriate treatment?

Question 8

A 68-year-old man undergoes emergency laparotomy for perforated diverticulitis. He develops massive surgical bleeding. Laboratory testing demonstrates:

• Platelets 180 ×10⁹/L

• PT 13 seconds

• APTT 32 seconds

• Fibrinogen 0.6 g/L

Massive transfusion protocol is underway.

Most appropriate treatment?

Question 9

A 57-year-old man taking rivaroxaban for recurrent venous thromboembolism presents with gastrointestinal haemorrhage. He is shocked and requires emergency endoscopy. Specific anti-Xa reversal agents are unavailable.

Most appropriate treatment?

Question 10

A 42-year-old woman develops persistent oozing following extensive dental extractions. Full blood count, PT, APTT, fibrinogen and platelet function studies are normal. Bleeding is predominantly mucosal and local measures have failed.

Most appropriate treatment?