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A Practical Guide to Haemostasis


Bleeding Assessment:
The ISTH-SSC Bleeding Assessment Tool [BAT]

Introduction

The ISTH BAT comprises 14 categories for assessing bleeding symptoms retrospectively and it has been shown that a high bleeding score is associated with the presence of an inherited bleeding disorder. Each of the 14 variables is scored from 0-4 [except for CNS Bleeding when the scores are 0, 3 or 4 and on the basis of this a final score is derived.

The 14 variables are listed below:

Epistaxis
Cutaneous Bruising
Bleeding from minor wounds
Oral Cavity Bleeding
GI Bleeding
Haematuria
Dental Extractions
Surgery
Menorrhagia
Post-partum Haemorrhage
Muscle Haematomas
Haemarthrosis
CNS Bleeding
Other Bleeding Problems



There are limitations to the ISTH-BAT:
i. It is relatively insensitive to children with a possible inherited bleeding disorder and this may lead to an underestimation of bleeding symptoms.  
ii. The ISTH-BAT is inflexible with respect to changes in the bleeding phenotype of the developing child. 
iii. The ISTH-BAT is relatively insensitive to acquired bleeding disorders.


The ISTH-BAT has been assessed as a screening tool for individuals with a possible inherited platelet function defect - see Gresele et al.  The ISTH-BAT can separate individuals with an inherited platelet function defect from controls but it is less efficient in separating an inherited platelet function defect from Type 1 VWD. Therefore, the ISTH-BAT appears useful for identifying subjects requiring laboratory evaluation for a suspected inherited platelet function defect once VWD has been excluded.

The ISTH-BAT:


Select Criteria:

Epistaxis
None/trivial 0 Points
>5/ Year or >10 minutes 1 Point
Consultation only 2 Points
Packing/Cauterisation/Antifibrinolytic agents 3 Points
Blood Transfusion or replacement agents [- haemostatic components/rVIIa] or Desmopressin 4 Points
Cutaneous Bruising
No/trivial 0 Points
5 or more [>1cm] in exposed areas 1 Point
Consultation only 2 Points
Extensive 3 Points
Spontaneous requiring Blood Transfusion 4 Points
Bleeding from minor wounds
No/trivial 0 Points
>5/ Year or >10 minutes 1 Point
Consultation only 2 Points
Surgical haemostasis 3 Points
Blood Transfusion or replacement agents or Desmopressin 4 Points
Oral Cavity Bleeding
No/trivial 0 Points
>5/ Year or >10 minutes 1 Point
Consultation only 2 Points
Surgical haemostasis or Antifibrinolytic agent 3 Points
Blood Transfusion or replacement agents or Desmopressin 4 Points
GI Bleeding
No/trivial 0 Points
Present - not associated with portal hypertension, ulcer, haemorrhoids, angiodysplasia 1 Point
Consultation only 2 Points
Surgical haemostasis or Antifibrinolytic agent 3 Points
Blood Transfusion or replacement agents or Desmopressin 4 Points
Haematuria
No/trivial 0 Points
Present - macroscopic 1 Point
Consultation only 2 Points
Surgical haemostasis, iron therapy 3 Points
Blood Transfusion or replacement agents or Desmopressin 4 Points
Dental Extractions
No/trivial or none done 0 Points
Reported in ≤ 25% of procedures, no interventions 1 Point
Reported in > 25% of procedures, no interventions 2 Points
Surgical haemostasis or Antifibrinolytic agent 3 Points
Blood Transfusion or replacement agents or Desmopressin 4 Points
Surgery
No/trivial or none done 0 Points
Reported in ≤ 25% of procedures, no interventions 1 Point
Reported in > 25% of procedures, no interventions 2 Points
Surgical haemostasis or Antifibrinolytic agent 3 Points
Blood Transfusion or replacement agents or Desmopressin 4 Points
Menorrhagia
No/trivial

0 Points
Consultation only
or
Changing pads more frequently than every 2 hrs
or
Clot sand flooding
or
PBAC Score >100

1 Point
Time of work/school >2X year 
or
Requiring Antifibrinolytic agents 
or
Hormonal therapy or iron therapy

2 Points
Requiring combined treatment with Antifibrinolytic agents and hormonal therapy
or
Present since menarche and >12 months

3 Points
Acute menorrhagia requiring hospital admission and emergency treatment
or
Blood Transfusion or replacement agents or Desmopressin
or
Requiring D & C or endometrial ablation or hysterectomy
4 Points
Post-partum Haemorrhage
No/trivial or no deliveries

0 Points
Consultation only
or
Use of syntocin
or
Lochia > 6 weeks

1 Point
Iron therapy
or
Antifibrinolytic

2 Points
Requiring Blood Transfusion, Replacement agents, Desmopressin
or
Requiring examination under anaesthesia and/or the use of uterine balloon package to tamponade the uterus

3 Points
Any surgical procedure requiring critical care or surgical intervention e.g. hysterectomy, iliac artery ligation, uterine artery embolisation, uterine artery bracing. 4 Points
Muscle Haematomas
Never 0 Points
Post-trauma, no therapy 1 Point
Spontaneous no therapy 2 Points
Spontaneous or traumatic requiring Desmopressin or replacement therapy 3 Points
Spontaneous or traumatic requiring surgical intervention or blood transfusion 4 Points
Haemarthrosis
Never 0 Points
Post-trauma, no therapy 1 Point
Spontaneous no therapy 2 Points
Spontaneous or traumatic requiring Desmopressin or replacement therapy 3 Points
Spontaneous or traumatic requiring surgical intervention or blood transfusion 4 Points
CNS Bleeding
Never 0 points
Subdural, any intervention 3 Points
Intracerebral, any intervention 4 Points
Other Bleeding Problems
No/trivial 0 Points
Present 1 Point
Consultation only 2 Points
Surgical haemostasis or Antifibrinolytic agent 3 Points
Blood Transfusion or replacement agents or Desmopressin 4 Points


Consultation only: The patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.


Score

[Max Score 56 points]

Interpretation:
Normal Range: Adult Males 0-3

A score ≥4 is considered 'abnormal'
Normal Range: Adult Females 0-5

A score ≥6 is considered 'abnormal'
Normal Range: Child [Age <18 years] 0-2

A score of ≥3 is considered 'abnormal'

A Bleeding Score <2 makes a Bleeding Disorder unlikely

See References for additional information.


Click HERE to re-set the ISTH-BAT algorithm.