Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • platelet count <20 x 109/L or if actively bleeding, presence of red cell fragments or blasts on blood film examination or associated with coagulation abnormalities.
  • platelet count < 50 x 109/L, with concurrent thrombosis

Please contact the duty haematologist via switchboard so the referral may be expedited, and the patient reviewed as soon as possible.

For clinical advice, please telephone the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network

Southern Adelaide Local Health Network

Inclusions

  • persistent unexplained thrombocytopenia

Exclusions

  • stable isolated thrombocytopenia attributed to non-haematological causes with platelet count ≥100 and no abnormalities on coagulation testing are usually not reviewed in clinic. Please re-refer if platelet levels drop.

Triage categories

Category 1 (appointment clinically indicated within 30 days)

  • persistent platelet level < 50 x 109/L
  • platelet count 50-100 x 109/L in association with:
    • other cytopenia (haemoglobin < 100g/L, neutrophils < 1 x 109 /L) splenomegaly, lymphadenopathy, pregnancy, or upcoming surgery

Category 2 (appointment clinically indicated within 90 days)

  • persistent, unexplained thrombocytopenia 50-80 x 109 /L

Category 3 (appointment clinically indicated within 365 days)

  • persistently low platelet level 80 x 109/L but <100 x 109/L

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • medication history including recent heparin administration
  • alcohol history
  • blood results:
    • complete blood examination (CBE)
    • blood film examination
    • liver function tests (LFTs)
    • electrolytes, urea, creatinine (EUC)
    • estimated glomerular filtration rate (eGFR)
    • B12
    • folate
    • lactate dehydrogenase (LDH)
  • coagulation studies including:
    • international normalised ratio (INR)
    • activated partial thromboplastin time (APTT)
    • fibrinogen
  • D-dimer
  • autoimmune screen, including screening for antiphospholipid syndrome
    • lupus anticoagulant
    • anticardiolipin
    • beta-2-glycoprotein-1 antibodies
  • viral screening including human immunodeficiency virus (HIV), hepatitis B and C serology

Additional information to assist triage categorisation

  • ultrasound upper abdomen

Clinical management advice

Thrombocytopenia is defined as platelet count <150 x 109/L. Most patients with platelet counts of >50 x 109/L are asymptomatic.

Given spurious thrombocytopenia due to collection, storage or in vitro clumping of platelets is not uncommon, all low results should be confirmed with repeat testing with a complete blood examination (CBE), coagulation screen and liver function tests within at least a week of initial recognition of thrombocytopenia. Suggest sending CBE analysis in an acid citric dextrose (ACD) tube which reduces platelet clumping.

Differential diagnosis of thrombocytopenia includes autoimmune causes such as idiopathic thrombocytopenic purpura (primary or secondary), drugs including alcohol misuse, primary marrow disorder, liver disease (with or without cirrhosis), hypersplenism, haematinic deficiency such as B12 or folate deficiency, microangiopathic haemolytic anaemia due to disseminated intravascular coagulopathy or thrombotic thrombocytopenic purpura.

Clinical resources

Consumer resources

Reason for request

  • to establish a diagnosis
  • for treatment or intervention
  • for advice and management
  • for specialist to take over management
  • for a specified test/investigation the General Practitioner cannot order
  • for other reason (e.g. rapidly accelerating disease progression)
  • transfer of care from another tertiary service
  • clinical judgement indicates a referral for specialist review is necessary.

Patient demographic details

  • full name, including aliases
  • date of birth
  • residential and postal address
  • telephone contact number/s – home, mobile and alternative
  • Medicare number, where eligible
  • name of the parent or caregiver, if appropriate
  • preferred language and interpreter requirements
  • identifies as Aboriginal and/or Torres Strait Islander

Clinical modifiers

  • impact on employment
  • impact on education
  • impact on home
  • impact on activities of daily living
  • impact on ability to care for others
  • impact on personal frailty or safety
  • identifies as Aboriginal and/or Torres Strait Islander

Other relevant information

  • Willingness to have surgery, where surgery is a likely intervention.
  • Choice to be treated as a public or private patient.
  • Compensable status, e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.
  • Relevant social history, including identifying if you feel your patient is from a vulnerable population, under guardianship/out-of-home care arrangements and/or requires a third party to receive correspondence on their behalf.
  • Triage of a specialist outpatient referral is based on clinical decision making to allocate an appropriate urgency categorisation.
  • Where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated public allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
  • A change in patient circumstance (such as condition deteriorating or pregnancy) may affect the urgency categorisation and should be communicated as soon as possible.
  • All new referrals will be triaged by a consultant and appointment times scheduled according to clinical urgency.