Plus-Hex CLINICAL acute bleeding . However , it may not make a significant enough impact due to the declining platelet factor after initial collection ( Walton & Tappin , 2021 ).
No single test can confirm a diagnosis of IMTP ( Lo & Deane , 2014 ) but a thorough clinical examination alongside detailed history gathering is essential for a diagnosis of IMTP to be made . Initial blood samples should be taken for blood gas , to monitor urea and nitrogen , and for a complete blood count ( CBC ), biochemistry and coagulation panel . An assessment of the patient ’ s blood smear ( Figure 3 ) should be done in-house for a manual platelet count and also sent away to a laboratory . As the patient at this point would be thought to have IMTP , it is very important that the bloods obtained are taken from a peripheral vein . A pressure bandage should be applied to reduce the risk of haemorrhage and further severe bruising .
IMTP can be caused by several diseases and infections , so it is important to rule out the most likely causes and determine whether IMTP is primary or secondary . Further blood sampling can be obtained for 4DX and angiosnap . This should be taken to check whether the patient has any tick-borne or infectious diseases such as ehrlichiosis or babesiosis which could be causing the patient to be thrombocytopenic ( Herrtage et al ., 2020 ).
Once the patient is deemed stable , sedation for further imaging , such as abdominal ultrasound and computed tomography ( CT ), would be recommended to discover whether the patient has primary or secondary IMTP . Intramuscular sedation should be avoided in these patients and an intravenous catheter placed with care to reach a sedated effect . Carrying out imaging on IMTP patients is an important requirement as this condition can be frequently associated with neoplasia ( secondary IMTP ). This goes hand in hand with carrying out a CBC , biochemistry and coagulation panel and urinalysis , to help pinpoint any underlying causes . Automatic analysers can sometimes deliver spurious results so it is always imperative to create a manual smear when obtaining a blood sample . Once a diagnosis is confirmed , treatment plans can be decided , based on these findings . However , if the patient is diagnosed with secondary IMTP then treatment of the secondary cause would be vital , alongside treating the IMTP .
Figure 4 . Dexamethasone treatment .
Treatment
In IMTP patients , the immune system has become extremely overactive and is causing life-threatening platelet destruction at a fast rate . Therefore , one of the essential initial actions is to try to suppress this overactivity of the immune system . Corticosteroids are the mainstay of treatment and are gold standard practice . Given their known efficacy , not to use them may be considered unethical ( Herrtage et al ., 2020 ). During initial stabilisation of IMTP patients , dexamethasone , which is a glucocorticoid steroid , is used as an intravenous medication ( Figure 4 ). Once stabilised on this , the patient can be moved to an oral corticosteroid medication , also known as prednisolone , which has functional anti-inflammatory properties . See the table ( Table 1 ) for other advantages of using corticosteroids in IMTP patients . The patient should also be monitored for any side effects outlined in the table .
The choice of which of the next two drugs are used will be clinician and case dependent . Two forms of immunosuppressive treatment can be used alongside prednisolone : cyclosporine and azathioprine . The
Table 1 . Advantages and side effects of using corticosteroids .
Advantages of using corticosteroids
Side effects of using corticosteroids
Works directly on cells , interrupting phagocytosis Polyuria and polydipsia ( PUPD ) Inhibits destruction of antibody-sensitive platelets by macrophages Can impair auto-antibody production
Increases capillary resistance to haemorrhage which , in return , reduces severity of haemorrhage while waiting for the platelet count to increase
May stimulate platelet production in some patients
Increased appetite Vomiting
Skin infections , due to immunosuppression
Steroid-induced diabetes
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