Page 77 - JSOM Summer 2022

Principles and Considerations in the Early Identification

and Prehospital Treatment of Thrombocytopenia

Katrina S. Nietsch, MS ; Timothy M. Roach ; Zachary D. Wilson ;
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Seth M. Kelly, MD, MBA, NRP *

ABSTRACT
Thrombocytopenia is a common condition characterized by a the remainder of the patient’s stay. On day 14, his platelet
low platelet count, typically less than 150,000/μL. This article count dropped to 6,000/μL. At this point, the patient was
outlines key considerations for field medical providers to ef- afebrile with a blood pressure of 160/80mmHg, heart rate of
fectively identify the early signs of thrombocytopenia and treat 102 bpm, and no noted bruising or petechiae. However, there
different etiologies in the prehospital environment. Following was notable oozing from the scalp lacerations where there
a representative case study, we present a review of basic patho- was previous hemostasis. A basic metabolic panel came back
physiology to include different manifestations of thrombocy- normal. However, given that the patient had been receiving
topenia as well as diagnostic methods, treatments, and other venous thromboembolism (VTE) prophylaxis during his stay,
necessary interventions in this unique setting. With an ade- the physician ordered a heparin-induced thrombocytopenia
quate understanding of typical patient histories and physical (HIT) antibody test; this was positive for HIT (heparin PF4)
presentations leading to this diagnosis, field medics and phy- antibodies. Additionally, a blood smear revealed large platelets
sicians can be armed with useful information to potentially but a decreased number of young platelets in circulation. The
improve patient outcomes. patient was started on a 4-day course of dexamethasone of
40mg daily.
Keywords: thrombocytopenia; platelets; bleeding; bruising
Shortly after, the patient began to deteriorate and was intu-
bated. Platelet transfusions were performed over the following
days with no significant change in platelet count. The dexa-
Introduction
methasone was halted and treatments of IV immunoglobulin
Thrombocytopenia is a common condition characterized by a at 0.4mg/kg daily for 5 days as well as IV methylprednisolone
low platelet count, typically less than 150,000/μL. This article at 500mg daily for 3 days were started. The patient showed
outlines key considerations for field medical providers to ef- no response to these treatments. At this point, on day 26, a
fectively identify the early signs of thrombocytopenia and treat bone marrow aspirate was performed which demonstrated a
different etiologies in the prehospital environment. presence of antibodies to human platelet alloantigen-5a. The
patient was diagnosed with post-transfusion purpura. He then
received three transfusions of 5a-negative platelets. The pa-
Case Study
tient’s platelet count increased from 3,000/μL to 21,000/μL
A 55-year-old man presented with T3 and T12 spine compres- during the course of these transfusions. On day 40, the pa-
sion fractures and scalp lacerations with active bleeding after tient’s platelet count had increased to 70,000/μL.
falling down an escalator. His history included hepatitis C, hy-
pertension, and heavy alcohol use. He reported being sober for
2 years prior to the incident. The bleeding was initially con- Basic Pathophysiology
trolled and he was admitted to the hospital for further man- Thrombocytopenia is a low number of platelets, or thrombo-
agement, where he experienced significant pain and confusion cytes, circulating in the blood. A systematic approach must be
during his extended stay. He was ordered for the following used to identify why the platelet count is low because differ-
medications upon admission to the hospital: nafcillin, enoxa- ent conditions may result in low platelets. Thrombocytopenia
parin, omeprazole, aspirin, furosemide, haloperidol, metopro- may be caused by decreased platelet production, sequestra-
lol, morphine, and vancomycin. tion, dilution, or increased platelet consumption resulting in
decreased platelet survival rates.
Upon admission, the patient’s initial laboratory testing re-
sults showed hemoglobin 10.0g/dL and platelets 200,000/μL. The etiologies of thrombocytopenia dictate the severity, clin-
Within three days, hemoglobin dropped to 5.6g/dL. He re- ical presentation, methods of evaluation and diagnosis, and
ceived 2 units of packed red blood cells (PRBCs), which in- treatment options. Research has shown that about 80% of
creased hemoglobin to 8.0g/dL and this remained stable for thrombocytopenia cases are not severe enough to require

*Correspondence to seth.kelly@gmail.com
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1 Katrina S. Nietsch is an active-duty pilot in the US Navy, based in Coronado, CA. Timothy Roach is an active-duty US Navy SOF medic, based
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in Virginia Beach, VA. Zachary D. Wilson is an active-duty US Navy Independent Duty Corpsman, based in Virginia Beach, VA. Dr Seth Kelly
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is an emergency medicine/emergency medical services physician affiliated with the Division of Prehospital and Disaster Medicine, Department of
Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
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