Rosen & Barkin's 5-Minute Emergency Medicine Consult (374 page)

One should consider CT of head in patients with signs or symptoms of central neurologic dysfunction to exclude intracranial hemorrhage.

• Bleeding and clotting disorders:
  
  • Platelet disorders (qualitative and quantitative)
    
  • Hereditary factor deficiencies
    
  • Acquired disorders (vitamin K deficiency, liver disease)
    
  • Disseminated intravascular coagulation
    

TREATMENT

IV fluid resuscitation with hemorrhage

• Rehydrate with 0.9% NS IV fluid.
  
• Bleeding or end-organ ischemia may not be controlled by any treatment except plasmapheresis.
  
• In patients with anemia and a leukemic picture, avoid blood transfusion until plasmapheresis is performed to avoid exacerbation of HVS.
  

• Hydration, supportive care, and early hematologist consultation are initial ED management.
  
• Phlebotomy or emergent plasma exchange: This temporizing measure can be performed in a patient with HVS and severe neurologic findings like coma or seizures:
  
  • Easily performed in the ED and is useful in acute severe cases if plasmapheresis not readily available
    
  • Simply draw off (100–200 mL) of whole blood and replace volume with isotonic saline.
    
  • Should be performed in consultation with hematologist when possible.
    
  • Treatment of choice in patients with polycythemia vera.
    
• Plasmapheresis/leukapheresis:
  
  • In stable patients: 40 mL/kg of body weight
    
  • In critical patients: 60 mL/kg of body weight
    
  • Side effects include hypocalcemia with use of a citrate-containing anticoagulant and dysrhythmia (rare).
    
    • Many patients require more than 1 plasmapheresis.
      
    • Definitive treatment for HVS. Should be performed in consultation with plasmapheresis/hematology team.
      
    • Leukapheresis is reserved as the initial treatment in patients with hyperleukocytosis (usually WBC >100,000)
      
• ED physician can help in urgent situations by establishing or facilitating the establishment of large-bore central dialysis catheter, caution should be taken to avoid bleeding complications of this procedure
  

FOLLOW-UP

• Patients with hyperviscosity and significant symptoms or any evidence of end-organ ischemia or hemorrhage should be admitted for treatment of the underlying hematologic disorder.
  
• ICU admission for the following:
  
  • Hemorrhage
    
  • Altered mental status
    
  • Acute MI
    

Discharge after definitive treatment of the underlying disorder.

All patients with HVS should be referred to hematologist.

• Avoid diuretics in patients with HVS because they can increase blood viscosity.
  
• The classic triad of symptoms of HVS includes visual disturbances, bleeding, and neurologic manifestations.
  

• Adams BD, Baker R, Lopez JA, et al. Myeloproliferative disorders and the hyperviscosity syndrome.
  Emerg Med Clin North Am
  . 2009;27:459–476.
  
• Blum W, Porcu P. Therapeutic apheresis in hyperleukocytosis and hyperviscosity syndrome.
  Semin Thromb Hemost.
  2007;33(4):350--354.
  
• Kwaan HC. Role of plasma proteins in whole blood viscosity: A brief clinical review.
  Clin Hemorheol Microcirc.
  2010;44(3):167–176.
  
• Somer T, Meiselman HJ. Disorders of blood viscosity.
  Ann Med
  . 1993;25(1):31–39.
  

See Also (Topic, Algorithm, Electronic Media Element)

Disseminated Intravascular Coagulation

CODES

• 273.3 Macroglobulinemia
  
• 289.0 Polycythemia, secondary
  

BASICS

• Blood in anterior chamber (AC) of the eye (between iris and cornea).
  
• Hyphema: Grossly visible layering of blood.
  
• Microhyphema: Suspended RBCs visible by slit-lamp only.
  
• Genetics:
  
  • Genetic predisposition is related to hereditary blood dyscrasias (see below).
    

• Blunt trauma: Most common (70–80%).
  
• Anteroposterior compression of the globe with simultaneous equatorial globe expansion causing rupture of iris stromal/ciliary body vessels
  
• Penetrating trauma: Direct injury to stromal vessels or sudden ocular decompression.
  
• Spontaneous: Less common, lower incidence of complications:
  
  • Tumors:
    
    • Melanoma
      
    • Retinoblastoma
      
    • Xanthogranuloma
      
    • Metastatic tumors
      
  • Blood dyscrasias:
    
    • Hemophilia
      
    • Leukemia
      
    • Thrombocytopenia
      
    • Von Willebrand disease
      
  • Blood thinners: Aspirin, Coumadin, heparin
    
  • Neovascularization of iris: In proliferative diabetic retinopathy, retinal vein occlusion, carotid stenosis.
    
  • Postsurgical: Cataract extraction, trabeculectomy, pars plana vitrectomy.
    

DIAGNOSIS

• Photophobia
  
• Blurring of vision
  
• Decreased visual acuity
  
• Ocular pain
  
• Nausea/vomiting
  

• Previous visual acuity
  
• Prior eye surgery
  
• Prior glaucoma treatment.
  
• Past medical history (blood disorders including sickle cell disease).
  
• Mechanism of trauma.
  
• Exact time of injury and of visual loss.
  
• History of excessive tearing after injury.
  

• General physical exam with emphasis on associated bodily injuries.
  
• Periorbital ecchymosis
  
• Eyelid lacerations
  
• Enophthalmos (depression of the globe within the orbit)
  
• Limited ocular movement with diplopia (may indicate orbital floor fracture)
  
• Proptosis (may indicate retro-orbital hemorrhage)
  
• Ocular exam:
  
  • Visual acuity
    
  • Rule out open globe (positive Seidel sign, corneal laceration, diffuse subconjunctival hemorrhage, decreased ocular motility, prolapse of intraocular structures)
    
  • Pupillary reaction to light (check for afferent pupillary defect prior to using dilating drops)
    
  • Tonometry for intraocular pressure (IOP) measurement