Hemorrhagic disorders of vascular origin
- Purpura simplex occurs with a higher susceptibility to ecchymosis, and for an increased vascular fragility. The disease is not serious.
- Hereditary hemorrhagic telangiectasia or Rendu-Osler-Weber disease with generalized vascular malformations can bleed frequently provoking epistaxis and sometimes serious hemorrhage of gastrointestinal origin.
- The treatment is that of the hemorrhagic complication and of the anemia caused.Gastrointestinal disorders are frequent, including abdominal pain and bleeding, and renal injuries with hematuria and proteinuria. Renal injury sometimes progresses to chronic renal insufficiency.The episode subsides in a few weeks, but frequently relapses after a disease-free interval. The treatment is symptomatic and corticoids help to improve the edema, and abdominal and joint pain.Schönlein-Henoch purpura is sometimes associated with the use of drugs and is characterized by purpura skin rash in the feet, legs, buttocks and leg extensor parts and often with fever, polyarthralgia and edema of the large joints, hands and feet.
- Some drugs, such as long-term corticoids, penicillins and sulfonamides, can also cause hemorrhagic disorders.
Advice on Hemorrhagic disorders of vascular origin
- Purpura simplex does not interfere with driving.
- Any hemorrhagic manifestation prevents from driving until the causal diagnosis is established and the hemorrhagic site is controlled.
- If nasal bleeding occurs while driving, it is very important to keep calm and stop the car as soon as possible ensuring the environment, which includes looking for the appropriate place, far from curves, such as the hard shoulder or entry to a track.
- If the condition does not subside in few minutes with compression, local ice, cold environment, it is recommended to ask for assistance to be transferred to an emergency department.
- In addition, the patient cannot drive while bleeding from the nose, that forces him to have one hand busy, with difficulty to see, to control the car controls, and the lack of attention in driving from being concerning with bleeding.
- Furthermore, the patient cannot drive while bleeding from the nose because it can be the symptom of another more serious disease that can also interfere with driving.
- Once the epistaxis is controlled and the cause identified, the physician will recommend driving if there is no risk of relapse of the clinical condition.
- If the patient has received medication, he will not leave the emergency driving even if he feels well.
- While the tamponade is in place, the patient can suffer craniofacial pain. It is advised against driving until it is removed by the physician and the absence of new bleeding is verified.
- The ability to drive is limited by lightheadedness, drowsiness and lack of attention, that are caused by anemia from repeated bleeding.
- Since drivers are more susceptible for the risk of bleeding, they should be recommended to maximize their caution when driving, in order to avoid any crash no matter how minimal it is.
Advice on Schönlein-Henoch purpura
- During the symptomatic period, the patient cannot drive, and he must be warned about it.
- The favorable evolution of the patient without organ involvement will enable the patient to drive again, always with a report from his physician in this regard.
- In the event of any evidence of recurrence, the patient cannot drive and must inform his physician and follow his directions.
Advice on Some drugs, such as long-term corticoids
- Any hemorrhagic episode prevents from driving until the hemorrhagic site is controlled and causal treatment is adjusted or removed.
- Lightheadedness, drowsiness, and lack of attention caused by anemia limit the ability to drive until the patient is stabilized.
Hemorrhagic disorders from platelet disease
Thrombocytopenia can be due to bone marrow injury, splenic sequestration, dilution, and increase in its destruction or use.
Thrombocytopenia can be associated in HIV infection, recent blood transfusion, significant alcohol intake, immunological disorders, systemic lupus erythematosus, lymphoma, and in therapy with heparin.
Other drugs that can cause thrombocytopenia in susceptible patients include quinidine, sulfonamides, oral antidiabetics, gold salts, rifampicin, thiazides, methyldopa, estrogens and chemotherapeutic agents.
Severe thrombocytopenia causes a hemorrhagic condition with multiple petechiae in the
legs, ecchymosis, epistaxis, and gastrointestinal, urologic or vaginal hemorrhages. Severe gastrointestinal and central nervous system bleeding can be very serious, and life-threatening.
Fever usually occurs in thrombocytopenia secondary to infection, in active systemic lupus erythematosus, and in thrombotic thrombocytopenic purpura.
Splenomegaly is frequent in patients with thrombocytopenia secondary to splenic platelet-sequestration, to lymphoma, or to myeloproliferative disease.
In secondary thrombocytopenia, the cause should be corrected, including discontinuation of heparin and the drugs in patients susceptible to them, treat the infection causing endotoxins, or induce remission in a patient with acute leukemia.
- In most adults, idiopathic thrombocytopenic purpura (ITP) starts with petechiae, purpura, and hemorrhage of various severities in the mucosal membrane, always with reduced platelet number.
The treatment starts with high doses of corticoids, requiring, if the patient responds, several weeks for platelet normalization, and some cases require splenectomy.
- Thrombotic thrombocytopenic purpura (TTP) is an acute disease that can beserious, and is associated with severe thrombocytopenia, hemolysis, fever and ischemic injuries in multiple organs, such as the central nervous system, the kidney, the myocardium and the digestive system.
This condition requires emergency hospital treatment.
Advice on Hemorrhagic disorders from platelet disease
- Any hemorrhagic episode prevents from driving until the hemorrhagic site is controlled and the causal treatment is adjusted or removed.
- The lightheadedness, drowsiness, and lack of attention caused by anemia limit the ability to drive until the patient is stabilized.
- The diseases associated with thrombocytopenia will establish, from the clinical condition, the real ability to drive at each time, always with a report and indication from the physician.
Advice on Idiopathic thrombocytopenic purpura
- The hemorrhage prevents from driving until the causal site is controlled and platelets return to normal ranges.
- The lightheadedness, drowsiness, and lack of attention caused by anemia limit the ability to drive until the patient is stabilized.
- Cases requiring splenectomy need a postoperative recovery period without driving, until the specialist physician reports on the complete recovery of the patient, both in hematology and wound healing.
Advice on Thrombotic thrombocytopenic purpura
- The patient cannot drive until the clinical condition has subsided completely, and always requires a favorable physician’s report indicating it.
- 6.5 Coagulation and thrombotic disorders and their interference with driving.
Blood coagulation disorders
They are characterized by a platelet count that may be normal, but these are not able to form normal hemostatic plugs.
They can be due to a frequently hereditary intrinsic platelet defect, or to an extrinsic factor affecting the function of previously normal platelets.
Hemophilia A and B:
- They can cause bleeding of various severity, so blows, surgical procedures and dental extractions should be avoided.
- In these patients the prevention of bleeding is essential; therefore, the patients should not take acetyl salicylic acid, and the use of ibuprofen in indispensable cases should be made with utmost care.
Von Willebrand’s disease:
- This platelet dysfunction is characterized by frequent bruising, mild to moderate bleeding evidenced in skin cuts, metrorrhagia, dental extractions and surgical procedures.
- The treatment indicated to beat bleeding episodes is prescribed on an individual basis by the specialized physician.
Acquired coagulation disorders:
- They are relatively frequent and associated with a broad range of myeloproliferative and myelodysplastic clinical conditions, uremia, macroglobulinemia, and multiple myeloma, cirrhosis and systemic lupus erythematosus.
- The drugs can also cause platelet dysfunction, as it is the case of penicillin and its derivatives, and acetyl salicylic acid.
- The leading causes of the acquired coagulation disorders are vitamin K deficits and liver diseases.
- Liver diseases cause disorders in the synthesis of coagulation factors, increased fibrinolysis, thrombocytopenia and together they can affect hemostasis.
- In some cases the manifestations are different, as in the case of some dysfibrinogenemias that can be associated with significant bleeding or with susceptibility to thrombosis.
- The thrombotic manifestations occurring in the adult age can be related to surgery or contraceptives, but in many cases no associated cause is identified.
- These patients with thrombotic episodes of congenital origin should receive anticoagulation therapy, based on the criterion of the specialist physician in each case.
Advice on Blood coagulation disorders.
- Any bleeding episodes is disabling for driving until the bleeding site is controlled.
- The replenishment of the factor deficit will be carried out by the specialized physician, who will report on the stabilization of the patient to be able to drive without risk increases.
- The ability to drive is limited by the dizziness, drowsiness, and lack of attention caused by anemia.
- The patient should be warned of the greater risk of suffering hemorrhages in case of minor blows, so caution should be exerted when driving.
Advice on Acquired coagulation disorders
- Patients with advanced liver disease are highly susceptible, not only for the increased risk of hemorrhage, but also for the associated symptoms making driving difficult for him.
- The physician will inform each patient of his ability to drive, without increasing the risks.
- Patients at risk of hemorrhage for the disease itself or for the anticoagulation therapy prescribed for the risk of thrombosis, should be closely monitored and warned of the risks of bleeding that can occur.
- They should be recommended to maximize precautionary measures when driving, since any small blow can be dramatic in them.
- The physician will advise against driving in the cases of high risk of bleeding or thrombosis.
The causes are many and varied, including venous stasis post-operatively, pregnancy, immobilization, etc., also vasculitis, myeloproliferative disorders, contraceptives, autoimmune conditions, thrombocytopenia by heparin, endogenous anticoagulation factors deficit, dysfibrinogenemia, etc.
- Anticoagulant drugs and their complications:
- Heparin is the agent of choice parenterally and its main complication is bleeding that requires discontinuation and, in serious cases, administration of protamine.
- Vitamin K antagonists are the treatment of choice by oral route, but require strict, individualized monitoring of doses.
Multiple drugs show pharmacological interactions with oral anticoagulants, due to the clinical importance involved by changes in hemostatic mechanisms.
Its effect is potentiated by chlorpromazine, sulfonamides, chloramphenicol, allopurinol, tricyclic antidepressants, laxatives, salicylates, thyroxin, androgens, antiarrhythmic such as amiodarone and quinidine, clofibrate, H2 antagonists, glucagon, disulfiram and some antibiotics including erythromycin, tetracycline, neomycin and imidazole-derivatives.
Its effect is reduced by vitamin K, barbiturates, rifampicin, cholestyramine, thiazides, carbamazepine, griseofulvin, and some oral contraceptives.
The administration with substances modifying hemostasis such as acetyl salicylic acid, phenylbutazone and pyrazolone derivatives is not recommended.
Vitamin K antagonists can increase hydantoin serum concentration and can also potentiate the hypoglycemic effect of sulfonylurea.
Patients treated with oral anticoagulants are susceptible to hemorrhagic complications, so anticoagulation therapy is adjusted individually for the dose and time.
Patients with chronic disease associated with a high incidence of thromboembolism will possibly require anticoagulation therapy in the long term.
Advice on Thrombotic disorders
- In the event of any suspect symptom or sign of thrombosis, the patient should be advised against driving, until the etiological diagnosis and the indicated treatment reverse the clinical symptoms.
- They patient cannot drive until the increased risk of a new episodes of thrombosis or embolism persists.
- Patients treated with oral anticoagulants should not take drugs containing acetyl salicylic acid.
- The patient should be warned not to take over-the-counter drugs, or those indicated by a physician who does not know that the patient is receiving anticoagulation therapy.
- Any new drug can destabilize the patient on anticoagulation therapy.
- When a drug is added or removed from the therapeutic regimen, prothrombin time should be monitored more frequently.
- It is advisable that patients treated on an ambulatory basis carry in their car a coagulation control sheet in case they are injured
- The patient should know his risk and to be responsible for his situation trying to perform a safe driving, that reduces the possibility of blows that, even if minor, can have dramatic consequences in him.