Patient handout

Thrombocytopenia symptom-triage (ED-primary; TTP/DIC/HIT/ITP/HELLP route + outpatient chronic)

PRODUCTION

1. Your condition

This handout is for thrombocytopenia symptom-triage (ed-primary; ttp/dic/hit/itp/hellp route + outpatient chronic). Your care team identified this based on: isolated thrombocytopenia (plt <100k, normal hgb + wbc, normal smear except large platelets) + no obvious secondary cause — primary itp; route heme.itp.core.v1 (acute) or heme.itp.chronic.v1 (>12 mo); first-line prednisone 1 mg/kg or dexamethasone 40 mg × 4 d; rescue ivig/anti-d + platelets if severe bleed (itp ash 2019 pmid 31585375).

Other reasons your team may use this plan: microangiopathic hemolytic anemia (schistocytes >2/hpf) + thrombocytopenia + ± neuro/renal/fever + plasmic score ≥6 + adamts13 <10% — ttp; stat plasma exchange (plex) — do not delay for adamts13; route heme.ttp.core.v1 (ttp isth 2017 pmid 31135051 verify); 4ts score ≥4-8 (thrombocytopenia 30-50% drop, timing 5-10d after heparin, thrombosis new venous/arterial, other cause excluded) + hit antibody (pf4 elisa) + functional confirmatory (sra) — heparin-induced thrombocytopenia; stop all heparin + alternative anticoag (fondaparinux/argatroban/bivalirudin) — avoid platelet transfusion (hit ash 2018 pmid 28811261 verify; 4ts pmid 23613659 verify); thrombocytopenia + prolonged pt/ptt + fibrinogen low <100 + d-dimer very high + clinical (sepsis, ob, trauma, apl, snake) + isth dic score ≥5 — dic; treat underlying + supportive (cryo for fibrinogen <100, ffp for inr >1.5, plt for plt <30k if bleeding); route heme.dic.v1 (dic isth 2018 pmid 26966077 verify).

3. When to call your provider

Contact your care team if any of the following happen:

Plt <30K + new bleeding → ED + IVIG + steroid + transfusion if life-threatening
Acute decompensation in chronic ITP → ED + reinduction
Pregnancy HELLP features (LFT high, hemolysis, low plt + HTN) → STAT OB + ED
HIT with new thrombosis on alt anticoag → ED + ICU
Active leukemia / MDS suspicion → STAT hematology + BMBx
Refractory chronic ITP failing steroid + IVIG + TPO-RA → splenectomy or rituximab
Post-splenectomy fever / infection → ED + broad-spectrum antibiotics (OPSI risk)
Hepatotoxicity from eltrombopag (LFT >3x ULN) → discontinue + switch romiplostim

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Microangiopathic hemolytic anemia (schistocytes >2/HPF) + thrombocytopenia + ± neuro/renal/fever + PLASMIC score ≥6 + ADAMTS13 <10% — TTP; STAT plasma exchange (PLEX) + caplacizumab + steroid 1 mg/kg + rituximab; DO NOT delay PLEX for ADAMTS13 result (TTP ISTH 2017 PMID 31135051 verify; HERCULES PMID 30625070 verify)(life-threatening)
4Ts score ≥4-8 (Thrombocytopenia 30-50% drop, Timing 5-10 d post-heparin, Thrombosis new venous/arterial, oTher cause excluded) + PF4 ELISA ≥1.0 OD ± SRA — HIT; STOP all heparin (UFH/LMWH/flushes) + alternative anticoag (fondaparinux 7.5 mg SC daily OR argatroban 2 µg/kg/min IV OR bivalirudin); AVOID platelet transfusion + warfarin until plt >150K (HIT ASH 2018 PMID 28811261 verify; 4Ts PMID 23613659 verify)(life-threatening)
Thrombocytopenia + prolonged PT/PTT + fibrinogen <100 + D-dimer very high + clinical (sepsis, OB, trauma, APL, snake) + ISTH DIC score ≥5 — DIC; treat underlying + supportive (cryo for fibrinogen <100, FFP for INR >1.5, plt for plt <30K bleeding); route heme.dic.v1 (DIC ISTH 2018 PMID 26966077 verify)(life-threatening)
Severe ITP (plt <30K + active bleeding OR plt <10K + asymptomatic) — IVIG 1 g/kg/d × 2 days + prednisone 1 mg/kg PO OR dexamethasone 40 mg × 4 d; platelet transfusion ONLY for life-threatening bleed (intracranial, GI, GU); route heme.itp.core.v1 (ITP ASH 2019 PMID 31585375)
Pregnancy 3rd trimester + Hemolysis (LDH high, indirect bili high, schistocytes) + Elevated LFT (AST/ALT >2x) + Low Platelets (<100K) + ± HTN >160/110 + proteinuria + RUQ pain — HELLP syndrome; DELIVERY definitive + magnesium 4 g IV load + 2 g/h infusion + corticosteroid 10 mg IV q12h × 4 (controversial)(life-threatening)
Sepsis criteria (SIRS / qSOFA / lactate >2) + thrombocytopenia (consumption + DIC overlap + bone marrow suppression) — sepsis-consumption; route id.sepsis.core.v1 for full Surviving Sepsis Campaign 1-h bundle; DIC workup if coagulopathy + bleeding
Plt <10K + spontaneous bleeding (intracranial, GI, retinal, GU) OR plt <20K + severe bleed OR plt <50K + procedure-induced — bleeding emergency; pRBC + platelet transfusion + cause identification + treat underlying (AVOID in HIT + TTP)(life-threatening)

5. Follow-up

Hematology for ITP chronic + HIT + TTP relapse + hereditary. ID for HIV/HCV/HBV viral suppression. Rheumatology for SLE flares. Obstetrics for HELLP postpartum + future pregnancy planning. Avoid future heparin exposure for HIT (lifelong); use fondaparinux/DOAC instead. ITP — vaccinations for splenectomy candidates; eltrombopag/romiplostim long-term monitoring (bone marrow fibrosis). Recurrence prevention.

6. Sources

Guideline: 2019 ITP ASH + 2017 TTP ISTH + 2018 HIT ASH + 2018 DIC ISTH + HERCULES caplacizumab + ITP Provan international consensus