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require treatment despite being below 150,000/μL. If the pa- Disclaimer
tient’s platelet count is greater than 50,000/μL then therapy to Opinions or assertions contained herein are the private views
increase the count is not generally needed, but below this level of the authors and are not to be construed as official or as re-
7
is when treatment is normally recommended. After the plate- flecting the views of the Department of Defense or its Services.
let level has been addressed then treatments will focus on man-
aging other bleeding factors and utilizing hemostatic products. Funding
If bleeding is found to be critical then a platelet transfusion is The authors received no funding for this effort.
the fastest way to remedy this. IVIG and glucocorticoids such
as dexamethasone or methylprednisolone may be utilized. As References
the severity decreases so do the therapies needed to support 1. Gauer RL, Braun MM. Thrombocytopenia. Am Fam Physician.
8
the individual patient. If glucocorticoids or IVIG do not pro- 2012;85(6):612-622.
duce a stable and safe platelet count, then the diagnosis will be 2. National Heart, Lung, and Blood Institute (NHLBI). Throm-
reevaluated and other immune modulators, immunosuppres- botic thrombocytopenic purpura. https://www.nhlbi.nih.gov/
health-topics/thrombotic-thrombocytopenic-purpura. Accessed
sive agents, or even splenectomy considered. 9 16 February 2022.
3. Healthline. Immune thrombocytopenic purpura diet: Foods to eat,
Another example of when to hold off on a treatment in the avoid, and more. https://www.healthline.com/health/itp/foods-to
case of a patient with thrombocytopenia would be a patient -eat-and-avoid. Accessed 16 February 2022.
with disseminated intravascular coagulopathy (DIC). In these 4. Garmo C, Bajwa T, Burns B. Physiology, Clotting Mechanism.
patients a platelet transfusion should be deferred unless there is [Updated 2021 Sep 8]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan-. Available from: https://www
10
active or a considerable risk of bleeding. To evaluate for DIC, .ncbi.nlm.nih.gov/books/NBK507795/
medics should consider prolonged coagulation activation, ele- 5. Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Grein-
vated fibrin markers, and low fibrinogen levels. Therapies may acher A. Evaluation of pretest clinical score (4 T’s) for the di-
also include adequate clotting factor replacement transfusions. agnosis of heparin-induced thrombocytopenia in two clinical
settings. J Thromb Haemost. 2006;4(4):759–765. doi:10.1111/j.
1538-7836.2006.01787.x
Conclusion 6. Greinacher A. Heparin-Induced Thrombocytopenia. NEJM. 2015;
373(3):252-261.
Thrombocytopenia is a condition that is common in critical 7. Morris TA, Castrejon S, et al. No difference in risk for throm-
care settings and may be encountered in the prehospital en- bocytopenia during treatment of pulmonary embolism and deep
vironment as well. It will most likely present in an austere venous thrombosis with either low-Molecular-Weight Heparin or
environment following hemorrhagic shock treated with large Unfractionated Heparin. Chest. 2007;132(4):1131-1139.
volumes of blood products for which a platelet transfusion 8. Blaes A. Case study: 55-year-old man with thrombocytopenia.
can be a beneficial treatment. This is not normally done in a Healio. 1 July 2007. https://www.healio.com/news/hematology
-oncology/20120325/case-study-55-year-old-man-with-thrombo-
field scenario given the limitations of diagnosis and treatment cytopenia. Accessed 16 February 2022.
in remote locations and the focus on moving a patient to a 9. Lab Tests Online. Heparin-induced thrombocytopenia PF4 anti-
higher level of care. The amount of medications to manage body. https://labtestsonline.org/tests/heparin-induced-thrombo-
coagulopathy and bleeding conditions (and reverse them if cytopenia-pf4-antibody. Accessed 16 February 2022.
needed) is a logistical burden that is not likely to be overcome 10. Kuter DJ. Thrombocytopenia due to splenic sequestration. Merck
unless partnering with a more permanent or advanced medical Manual. June 2020. https://www.merckmanuals.com/professional
/hematology-and-oncology/thrombocytopenia-and-platelet-dys-
resource. There are several other types of thrombocytopenia function/thrombocytopenia-due-to-splenic-sequestration. Accessed
that are less common in a traditional Special Operations envi- 16 February 2022.
ronment but are nevertheless important for which medics to be
familiar. Evaluation of these is traditionally aided by labora- Bibliography
tory methods. However, a deployed provider may have to rely Bambrah RK, Pham DC, et al. Heparin-induced thrombocytopenia.
on clinical decision making alone. As technologies and testing Clin Adv Hematol Oncol. 2011;9(8):594-599.
modalities advance, and the logistics of implementation revis- Coutre S, Crowther M. Management of heparin-induced thrombocyto-
ited, it may be the case in the future in which the treatment of penia. UpToDate. https://www.uptodate.com/contents/management
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thrombocytopenia is advanced closer to the point of injury or George JN, Arnold DM. UpToDate. https://www.uptodate.com/
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Author Contributions 21, 2021.
KN and SK developed the project plan and initial outline of Lab Tests Online. Heparin-induced Thrombocytopenia PF4 Antibody.
the manuscript. All authors coordinated, collected, and pre- https://labtestsonline.org/tests/heparin-induced-thrombocytopenia
-pf4-antibody. Accessed May 20, 2021.
sented the information included in the manuscript. KN, TR, Levi M, Toh CH, Thachil J, Watson HG. Guidelines for the diagnosis and
and ZW wrote the first draft with technical guidance and ini- management of disseminated intravascular coagulation. Br J Haema-
tial review by SK. All authors read, edited, and approved the tol. 2009;145(1):24–33. doi:10.1111/j.1365-2141.2009.07600.x
final manuscript. Merck Manuals Professional Edition. https://www.merckmanuals.
com/professional/hematology-and-oncology/thrombocytopenia
-and-platelet-dysfunction/thrombocytopenia-due-to-splenic
Disclosures -sequestration. Published June 2020. Accessed May 20, 2021.
The authors have indicated they have no financial relation- Neunert C, Terrell DR, Arnold DM, et al. American Society of He-
ships relevant to this article to disclose. matology 2019 guidelines for immune thrombocytopenia. Blood
Adv. 2019;3:3829.

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