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Most bleeding seen in the emergency department is due to trauma, the result of local wounds, lacerations, or other structural lesions that occur in patients with normal hemostasis. Conversely, bleeding from multiple sites, bleeding from untraumatized sites, delayed bleeding several hours after trauma, and bleeding into deep tissues or joints suggest the possibility of a bleeding disorder. Historical data for the presence of a congenital bleeding disorder include the presence or absence of unusual or abnormal bleeding in the patient and other family members and the possible occurrence of excessive bleeding after dental extractions, surgical procedures, or trauma. Many patients with abnormal bleeding have an acquired disorder, commonly due to liver disease or drug use (particularly ethanol, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], warfarin, and antibiotics).

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The site of bleeding may provide an indication of the hemostatic abnormality. Mucocutaneous bleeding, including petechiae, ecchymoses, epistaxis, or gastrointestinal, genitourinary, or heavy menstrual bleeding, is characteristic of qualitative or quantitative platelet disorders. Purpura is often associated with thrombocytopenia and commonly indicates a systemic illness. Bleeding into joints and potential spaces, such as between fascial planes and into the retroperitoneum, as well as delayed bleeding, is most commonly associated with coagulation factor deficiencies. Patients who demonstrate both mucocutaneous bleeding and bleeding in deep spaces may have disorders such as disseminated intravascular coagulation (DIC), in which both platelet abnormalities and coagulation factor abnormalities are present. Basic hemostatic tests and clinical evaluation are generally adequate for diagnosis (Table 41–1). Additional hemostatic studies are ordered as indicated (Table 41–2).

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Table 41–1. Standard Tests of Hemostasis.
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Table 41–2. Specialized Tests of Hemostasis.

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