Ecchymosis – Diagnosis & Treatment
Dermatology, Hematological / Oncological
Bruising (ecchymosis) results from the extravasation of blood beneath intact skin, most often due to trauma.
- When discordant with the degree of trauma may be caused by an underlying bleeding disorder.1,2
- Up to 55% of otherwise healthy individuals will present with easy bruising.1,2
Major etiologies of bruising include:1,2
- Trauma: accidental, non-accidental.
- Vascular disorders: senile purpura, simple purpura, connective tissue diseases, vitamin C deficiency.
- Platelet disorders: immune thrombocytopenia, thrombotic thrombocytopenic purpura, aplastic anemia, hematologic malignancies, congenital/inherited platelet disorders.
- Coagulation disorders: Von Willebrand disease, hemophilia A, hemophilia B, liver disease, vitamin K deficiency.
- Drugs: alcohol, corticosteroids, aspirin, NSAIDs, clopidogrel, SSRIs, certain antibiotics, thiazide diuretics, warfarin, heparin, DOACs.
- Consider relevant medical conditions, medications, social history, and family history.1,2,3
- Consider including a specific bleeding/bruising history. The International Society on Thrombosis and Hemostasis Bleeding Assessment Tool may be used to guide questioning.1,2,3
- Rule out abuse in pediatric, geriatric, and vulnerable populations.
- Red flags for bruises associated with physical abuse include:1,2,3
- Bruises discordant with the given explanation.
- Bruises on not yet mobile children.
- Bruises on torso, buttocks, ears, or neck.
- Bruises that are large, numerous, clustered or patterned in the shape of a striking implement.
- Bruises location, size, shape, number, etc., joints, abdomen, head, neck, and lymph nodes.
- Normal bruises tend to be small, relatively round, have non-distinct borders, and appear over bony prominences on the anterior surface of the body.1,2
- Bruises indicative of an underlying bleeding disorder may be persistent, spontaneous, numerous (>5), large (>1cm), or appear in abnormal locations (e.g. trunk, back, and face).1,2
- Mucocutaneous bleeding suggests vasculature, Von Willebrand factor, or platelet disorders.1,2
- Petechiae suggests severe thrombocytopenia.1,2,3
- Purpura suggests thrombocytopenia or vasculature disorders.1,2
- Hemarthroses or muscle hematomas are indicative of coagulation factor disorders (e.g. hemophilia).1,2,3
- Joint or skin laxity may indicate a connective tissue disorder.1,2,3
- Hepatosplenomegaly may indicate liver or systemic disease.1,2,3
- Complete blood count (CBC) with differential.
- Prothrombin time (PT) or international normalized ratio (INR).
- Activated partial thromboplastin time (PTT).
- Liver, renal, and thyroid function tests.
Bruising with no suspicion of an underlying bleeding disorder can be treated with simple analgesia (acetaminophen, ibuprofen, etc.) and patient reassurance.2
- Clinically stable patients with continued unexplained bruising/bleeding, with or without abnormal laboratory investigations, should be referred to a hematologist.2 Urgency relies on clinical judgment of severity.
- Admit patients with significant active bleeding that is unresponsive to initial management (e.g. compression).2 Admit vulnerable patients if abuse is suspected; abuse should be reported to the appropriate government agency.2
- Medications suspected to be causing bruising should be discontinued, if possible.2
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated May 03, 2021
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