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Curriculum standards

Knowledge guides

LG23: Bleeding

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Presentations
  • Abnormal coagulation tests
  • Family history of life-threatening bleeding or excessive bruising
  • Heavy menstrual bleeding and/or iron deficiency
  • Kidney dysfunction
  • Neurological dysfunction
  • Prior history of life-threatening bleeding after surgery or postpartum haemorrhage
  • Spontaneous bleeding or bruising
  • Thrombocytopenia
Conditions
  • Acquired bleeding disorders:
    • coagulopathy associated with:
      • liver disease
      • kidney disease
      • nutritional deficiency:
        • vitamin K
    • disseminated intravascular coagulation
    • drug-induced bleeding, including:
      • anticoagulants
      • antiplatelets
      • antithrombotic therapy
      • Bruton’s tyrosine kinase inhibitors
      • non-steroidal anti-inflammatories (NSAIDs)
      • selective serotonin reuptake inhibitors
    • haemophilia
    • immune thrombocytopenia (ITP)
    • medication-related thrombocytopenia
    • microangiopathies, including:
      • atypical haemolytic uraemic syndrome
      • thrombotic thrombocytopenia purpura
    • trauma-induced coagulopathy
    • von Willebrand disease
  • Bleeding disorder of unknown cause
  • Inherited bleeding disorders:
    • haemophilia:
      • A
      • B
    • von Willebrand disease
  • Pregnancy:
    • differential diagnosis, investigation, and management of thrombocytopenia during pregnancy
    • management of bleeding disorders during pregnancy

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Presentations
  • Bleeding
  • Bruising
  • Epistaxis
Conditions
  • Acquired or congenital platelet function disorders, such as:
    • Bernard–Soulier syndrome
    • Glanzmann thrombasthenia
    • storage pool diseases
  • Cirrhosis
  • Congenital disorders of fibrinogen – number or function
  • Connective tissue disorders, such as vascular Ehlers–Danlos syndrome
  • Hereditary haemorrhagic telangiectasia
  • Nutritional:
    • vitamin K deficiency
  • Rare congenital factor deficiencies:
    • factor II
    • factor V
    • factor X
    • factor XI
    • factor XIII

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
  • Aetiology, diagnosis, management, and natural history of congenital and acquired disorders of platelet number and/or function
  • Complement system relating to atypical haemolytic uremic syndrome
  • Laboratory assessment of platelet number and function, including limitations
  • Mechanism of action and adverse effects of medications / compounds with antiplatelet activity
  • Platelet structure and function

Acquired bleeding disorders

  • Adverse effects, indications for use, and mechanisms of action of available haemostatic agents, including:
    • anti-fibrinolytics
    • blood and coagulation factor products
    • desmopressin (DDAVP)
    • other adjunctive agents
  • Normal haemostasis and fibrinolytic mechanisms
  • Pathophysiology of acquired bleeding disorders, including:
    • acquired factor deficiency, especially factor VIII (FVIII) coagulant (FVIIIC) and von Willebrand factor (vWF)
    • disseminated intravascular coagulation (DIC)
    • hepatic disease
    • kidney disease
    • massive transfusion
    • obstetric complications

Inherited bleeding disorders

  • Complications, diagnostic strategies, natural history, and presentation of:
    • coagulation factor inhibitors
    • inherited coagulation disorders, in particular deficiencies of:
      • factor IX
      • FVIII
      • vWF
  • Diagnostic methods used in assessment of inherited coagulation disorders, including specific assays
  • Mechanism of action, indications for use, and side effects of available coagulation factor concentrates and relevant haemostatic agents
  • Molecular biological techniques to identify genetic disorders
  • Pathophysiology of normal haemostasis
Clinical assessment tools
  • Bleeding assessment tools, such as the International Society on Thrombosis and Haemostasis Bleeding Assessment Tool (ISTH-BAT)
  • Other widely accepted pretest probability tools, such as the 4T score and the PLASMIC score for life-threatening conditions affecting platelet count
Investigations
  • Anticoagulant medication levels
  • Complement testing
  • Heparin-induced thrombocytopenia screening and confirmatory testing
  • Investigation of abnormal coagulation studies
  • Platelet function assays, including light transmission aggregometry and automated analysers, such as PFA100/200
  • Viscoelastic testing, including:
    • rotational thromboelastometry (ROTEM)
    • thromboelastography (TEG)
Procedures and management
  • Appropriate treatment for bleeding and thrombocytopenia, including blood transfusion
  • Complement inhibitors and supportive care
  • Delivery of desmopressin and potential risks
  • Factor replacement and use of haemostatic therapies
  • Gene therapy for haemophilia and hemoglobinopathy
  • Management of immune thrombocytopenic purpura (ITP), including:
    • emergency interventions for life-threatening bleeding
    • first- and second-line strategies
  • Management of patients with bleeding disorders prior to and during surgery
  • Management of spontaneous bleeding
  • Management of trauma in patients with bleeding disorders
  • Reversal agents for anticoagulant therapies