Does the patient require treatment prior to surgery and, if so, what treatment?

The patient's platelet count is normal, ruling out thrombocytopenia, and a single dose of ibuprofen would not be expected to result in a severe tissue hemorrhage, even with trauma. The PTT is prolonged, suggesting an abnormality of the “intrinsic” coagulation factors XI, IX, or VIII. Since this patient has no history of hemophilia A or B, a “mixing study” using aI: Idilution of patient plasma with pooled normal plasma to exclude an inhibitor is in order. A platelet function assay for von Wille brand disease is also indicated. The results in this patient are as follows: Inhibitor mixing assay – PTT (@ time 0) = 34 seconds (control = 32 seconds) PTT (@ 60 minutes) = 56 seconds (control = 34 seconds) Platelet function assay – PFA collagen/ADP closure time = 95 seconds (80-120 seconds); PFA collagen/epinephrine closure time = 145 seconds (I I 0- 1 80 seconds) At the same time, a computed tomography (CT} scan of the right shoulder and arm demonstrates a large hematoma within and surrounding the muscles of the upper arm and extending from the axilla through the brachial plexus and into the forearm. The vascular surgeon recommends immediate surgery to relieve the compartment syndrome, but because of the coagulation results, the surgeon requests a consult for management of the coagulopathy.

Questions

• Based on these results, what is the most likely cause of the coagulopathy and how can this be confirmed?

• Does the patient require treatment prior to surgery and, if so, what treatment?

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