Clinical Commander

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heme.itp.core.v1

Immune Thrombocytopenia (ITP) — initial diagnosis & acute Rx

hematologyacutesubacuteadultpediatricacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Manifest is full but no _design-brief and no problem package on disk. Per heuristic still INTEGRATED via manifest + atoms + evidence + linked workup + ≥1 calculator (4Ts). RxCUIs absent from manifest; pending validation via scripts/research/rxnav-validate.ts. Chronic transition routes to heme.itp.chronic.v1 (currently SCAFFOLDED).

Entry points (3)

  • lab_abnormality
    Isolated thrombocytopenia (platelet count <100k) with otherwise normal CBC — ASH 2019 Neunert
    isolated_thrombocytopenia
  • symptom
    Petechiae / purpura / mucocutaneous bleeding — ASH 2019 Neunert
    mucocutaneous_bleeding
  • symptom
    Major bleeding (intracranial/GI) — emergency presentation — ASH 2019 Neunert; BSH 2024
    major_bleeding

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    Pediatric ITP often self-limited (70–80% remit ≤6mo); adult management distinct — ASH 2019 Neunert
  • platelet_countrequired
    lab • used at ENTRY
    Severity tier: <30k high-risk; <10k major bleed risk — ASH 2019 Neunert
  • cbc_with_diffrequired
    lab • used at INITIAL_WORKUP
    Rule out other cytopenias (Evans, MDS, leukemia, aplastic) — ASH 2019 Neunert; BSH 2024
  • peripheral_smearrequired
    lab • used at INITIAL_WORKUP
    Rule out pseudothrombocytopenia, schistocytes (TTP/HUS), blasts — ASH 2019 Neunert; Provan 2019
  • coag_panelrequired
    lab • used at INITIAL_WORKUP
    Rule out DIC; baseline before procedures — ASH 2019 Neunert
  • recent_drugsrequired
    history • used at CONTEXT
    Drug-induced ITP (heparin → 4Ts; quinine, vanc, sulfa, etc.) — ASH 2019 Neunert; Provan 2019
  • autoimmune
    history • used at CONTEXT
    SLE, APS, CVID screen → secondary ITP — ASH 2019 Neunert; BSH 2024
  • recent_infection
    history • used at CONTEXT
    Viral (HIV, HCV, H. pylori, EBV, CMV); post-vaccination — ASH 2019 Neunert
  • pregnancy
    history • used at CONTEXT
    Pregnancy-associated ITP vs gestational thrombocytopenia — ASH 2019 Neunert; NICE 2024

12-phase flow (12)

  1. 1FRAME
    Confirm isolated thrombocytopenia + exclude pseudothrombocytopenia (citrate tube), drug-induced, secondary causes — ASH 2019 Neunert; Provan 2019
    inputs: platelet_count, cbc_with_diff, peripheral_smear
    advance: Primary ITP diagnosis remains after exclusions
  2. 2ENTRY
    Stratify by platelet count + bleeding (ITP-BAT) — ASH 2019 Neunert; Provan 2019
    inputs: platelet_count
    advance: Severity + bleeding tier set
  3. 3CONTEXT
    Capture drug history (heparin → 4Ts), autoimmune, infection, pregnancy — ASH 2019 Neunert; BSH 2024
    inputs: recent_drugs, autoimmune, recent_infection, pregnancy
    advance: Trigger review complete
  4. 4RED_FLAGS
    Major bleeding (ICH/GI) + plt <10k → STAT IVIG + steroids + platelet transfusion + TXA + emergency Rx — ASH 2019 Neunert; BSH 2024
    inputs: platelet_count
    advance: Emergency bleeding stabilized
  5. 5INITIAL_WORKUP
    CBC + diff + smear + retic; coag; HIV / HCV / H. pylori; quantitative immunoglobulins; ANA; DAT (Evans) — ASH 2019 Neunert; BSH 2024
    inputs: cbc_with_diff, peripheral_smear, coag_panel
    actions: panel.cbc, panel.coag, workup.itp_standalone
    advance: Secondary causes excluded
  6. 6BRANCHING_WORKUP
    Bone marrow biopsy if atypical (age >60, refractory, other cytopenias); 4Ts if heparin; ADAMTS13 if MAHA suspected — ASH 2019 Neunert; BSH 2024
    actions: calc.4ts
    advance: Atypical features resolved
  7. 7DIFFERENTIAL
    Primary ITP / secondary (drug, autoimmune, viral, post-transfusion, vaccine-induced) / Evans / MDS / TTP / HIT / DIC — ASH 2019 Neunert; Provan 2019
    advance: Subtype assigned
  8. 8RISK_STRATIFICATION
    ITP-BAT bleeding score; thrombosis risk for TPO-RA; pregnancy management tier — ASH 2019 Neunert; Provan 2019
    advance: Risk documented
  9. 9TREATMENT
    Plt ≥30k + no bleeding → observe. Plt <30k or bleeding → dexamethasone 40 mg ×4d or prednisone 1 mg/kg; IVIG 1 g/kg ×1–2d for rapid response; major bleed → IVIG + IV methylpred + plt transfusion + TXA. Second-line: TPO-RA (romiplostim/eltrombopag/avatrombopag); rituximab; fostamatinib. Splenectomy reserved. — ASH 2019 Neunert; Provan 2019; Bussel 2021
    inputs: platelet_count
    advance: Plan executed; if chronic → route to heme.itp.chronic.v1
  10. 10DISPOSITION
    Inpatient if plt <20k + bleeding; ICU if major bleed; outpatient otherwise with hem follow-up — ASH 2019 Neunert; BSH 2024
    advance: Disposition set
  11. 11MONITORING
    Plt count q24–72h while titrating; LFTs on eltrombopag/fostamatinib; thrombosis surveillance on TPO-RA; steroid toxicity surveillance — ASH 2019 Neunert; NICE 2024
    inputs: platelet_count
    actions: panel.cbc
    advance: Monitoring schedule documented
  12. 12FOLLOWUP
    Hem clinic follow-up; vaccination plan if rituximab/splenectomy planned; transition to chronic engine if persistent >12 months — ASH 2019 Neunert; BSH 2024
    advance: Follow-up scheduled