Confirm that the bleeding is excessive

Normal PT and aPTT

and that a coagulopathy is a likely cause

No
Are the PT / aPTT false-negatives?
Yes / N ot sure

Redraw and repeat

Platelet defects
PT / aPTT
Pursue defects in
primary hemostasis
von Willebrand disease Rule out patient-specific causes
Transient coagulopathy (medication, dilutional coagulopathy),
coagulopathy masked by therapy (transfusion) or clinical
setting (pregnancy, acute phase, etc.)
Factor XIII deficiency
Consider additional
defects in Rule out preanalytic causes
secondary hemostasis Fibrinogen and Wrong patient drawn, improper specimen collection
specific factor assays and handling, etc.

Consider defects in Rule out analytic causes

fibrinolysis Incorrect reference range, incorrect international sensitivity
index (ISI), poor factor sensitivity, etc.

Rule out postanalytic causes

Consider
Transcription errors, calculation errors
vascular disorders
(international normalized ratio [INR])

A n a l g o ri t hm i c a p pr o a c h t o t he di a gn o si s o f a b l e e d i ng e t i o l o g y blood from the wrong patient. If a coagulopathy is likely, further

in a patient with a normal prothrombin time (PT) and activated partial directed workup would seek to rule out platelet dysfunction, von
thromboplastin time (aPTT). Initial evaluation should confirm that the Willebrand disease, fibrinolysis abnormalities, as well as factor XIII
bleeding is truly excessive and that the PT and aPTT results are not and fibrinogen abnormalities. Negative workup for all of these would
false-negative results due to recent transfusion therapy or drawing prompt a clinical evaluation to exclude vascular disorders.