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Clinical Medicine 2 > Approach to bleeding and thrombosis > Flashcards

Approach to bleeding and thrombosis Flashcards

1
Q

What is defined as the arrest of bleeding?

A

hemostasis

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2
Q

What are the components of hemostasis?

A
  • vasculature (endothelial cells and subendothelial matrix)
  • platelets
  • blood proteins (clotting factors)
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3
Q

What is the sequence of events of hemostasis?

A
  1. vascular injursy leads to vasoconstriction
  2. formation of a platelet plug (primary hemostasis)
  3. tissue factor activates coagulation cascade
  4. formation of a blood clot (secondary hemostasis)
  5. clot retraction and clot dissolution
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4
Q

What are vascular spasms triggered by?

A
  1. direct injury to vascular smooth mm
  2. chemicals released by endothelial cells and platelets
  3. pain reflexes
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5
Q

Pertaining to step 1 of hemostasis, vascular spasms:
- vessels respond to injury with (…)
- most effective in what type of blood vessels?
- can significantly reduce (…) until other mechanisms kick in

A
  • vasoconstriction
  • smaller blood vessels
  • blood flow
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6
Q

Pertaining to step 2 platelet plug formation of hemostasis:
- platelets stick to (…) that are exposed when vessels become damaged
- platelets do not stick to intact vessel walls because (…) is not exposed
- (…) and (…) which are secreted by endothelial cells act to prevent platelet sticking, therefore, keeps the platelets away

A
  • collagen fibers
  • collagen
  • prostacyclins and nitric oxide
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7
Q

What helps stabilize platelet-collagen adhesion?
Where is this found?

A
  • Von Willebrand Factor (VWF)
  • on platelets
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8
Q

Sometimes there can be too much collagen present which increases the risk of what?

A

clotting

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9
Q

Pertaining to step 2 platelet plug formation of hemostasis:
- What happens to platelets when they are released?
- Platelet plug formation is known as a (…) cycle; explain this
- Platelet plugs are fine for (…), but (…) in vessels need additional steps

A
  • platelets swell, become spiked and sticky, and release chemical messengers
  • positive feedback cycle; as more platelets stick, they release more chemicals, which cause more platelets to stick and release more chemicals
  • small vessel tears; larger breaks
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10
Q

What are the chemical messengers that platelets release when they are activated?

A
  • ADP
  • Serotonin
  • thromboxane A2
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11
Q

Which chemical messenger released by platelets causes more platelets to stick and release their contents, increasing platelet aggregation?

A

ADP

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12
Q

Which chemical messenger(s) released by platelets enhances vascular spasm and platelet aggregation?

A

serotonin and thromboxane A2

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13
Q

Pertaining to step 3 coagulation of hemostasis:
- Coagulation (blood clotting) reinforces (…) with (…)
- Blood clots are effective in sealing (…) vessel breaks
- Blood is transformed from (…) to (…)
- Series of reactions use (…), mostly (…)
- Coagulation occurs in (…) phases

A
  • platelet plug with fibrin threads
  • larger vesse breaks
  • liquid to gel
  • clotting factors (procoagulants), mostly plasma proteins
  • three phases
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14
Q
  • What are the numbers of clotting factors?
  • Vitamin K is needed to synthesize four factors, (…), along with protein (…) and (…)
A
  • I to XIII (no VI); numbered in order of discovery
  • II, VII, IX, X; protein C and S
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15
Q

What are the 2 different pathways of coagulation?

A
  • intrinsic pathway
  • extrinsic pathway
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16
Q

Which coagulation pathway is this describing:
- vessel endothelium ruptures, exposing underlying tissues; platelets clind and their surfaces provide sites for mobilization of factors?

A

intrinsic pathway

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17
Q

Which coagulation pathway is this describing:
- tissue cell trauma exposes blood to tissue factor (TF) (occurs extrinsic to the vascular wall)

A

extrinsic pathway

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18
Q
  • What is the first clotting factor that activates the coagulation cascade in the intrinsic pathway?
  • Which clotting factors follow this?
A
  • clotting factor XII
  • XI, IX, VIII comes in and activates, IX/VIII complex is formed
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19
Q

What is the pathway of coagulation in the extrinsic pathway?

A
  • begins with tissue factor
  • Ca2+ (considered facor IV) comes in
  • factor VII comes in, is activated, then communicates with the intrinsic pathway
  • TF/VII complex is formed
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20
Q
  • Which factor is where the common coagulation pathway begins?
  • What activates this factor?
A
  • factor X
  • IX/VIII complex + TF/VII complex
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21
Q

What does phase 2 of coagulation consist of?

A

prothrombin (factor II) converts to thrombin (IIa)

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22
Q

What does phase 3 of coagulation consist of?

A

fibrinogen (factor I) converts to fibrin and with the help of Ca2+ and XIII, a cross-linked fibrin mesh is formed

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23
Q

What is activated when tissue trauma occurs?

A

extrinsic pathway

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24
Q

What is activated under conditions such as stress, anxiety, or fear, and in the abscence of external tissue injury?

A

intrinsic pathway

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25
Q

In stage one of the coagulation cascade, either the extrinsic or intrinsic pathway ends with the formation of (…)

A

prothrombin-converting factor

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26
Q

In stage two of the coagulation cascade, prothrombin-converting factor begins a series of chemical interactions which slowly converts (…) to (…)

A
  • prothrombin
  • thrombin
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27
Q

In stage 3 of the coagulation cascade, What happens?

A

fibrinogen interacts with thrombin to form fibrin

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28
Q

What all collect at the site of injury to complete thrombosis development?

A

erythrocytes, phagocytes, and microorganisms

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29
Q

What time is used to evaluate how well the intrinsic pathway of coagulation is working?

A

activated partial thromboplastin time (aPTT)

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30
Q

What is the typical time frame of aPTT?

A

25-39 seconds

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31
Q

The pTT is used to evaluate what factors?

A
  • XII
  • XI
  • IX
  • VIII
  • X
  • V
  • II (prothrombin)
  • I (fibrinogen)
32
Q

What time is used to evaluate how well the extrinsic coagulation pathway is working?

A

prothrombin time

33
Q

What is the typical time frame for PT?

A

12 seconds

34
Q

The PT test evaluates which clotting factors?

A
  • VII
  • X
  • V
  • II
  • I
35
Q

What are most clotting factors made?

A

the liver

36
Q
  • Which clotting factor is involved in the common pathway and is converted to fibrin?
  • What is the factor name?
  • Where is this made?
A
  • I
  • fibrinogen
  • liver
37
Q
  • Which clotting factor is involved in the common pathway and is converted to thrombin (converts fibrinogen to fibrin)?
  • What is the factor name?
  • Where is this made?
A
  • II
  • prothrombin
  • liver
38
Q
  • Which clotting factor activates the extrinsic pathway?
  • What is the name of this factor?
  • Where is this made?
A
  • III
  • tissue factor (TF)
  • tissue cells
39
Q
  • Which clotting factor is needed for all stages of the coagulation process as it is always present?
  • What is the name of this factor?
  • Where is it made?
A
  • IV
  • Calcium ions (Ca2+)
  • plasma
40
Q
  • Which clotting factor functions in the common pathway?
  • Where is this made?
A
  • V
  • liver, platelets
41
Q
  • Which clotting factor functions both in the extrinsic and extrinsic pathways?
  • Where is this made?
A
  • VII
  • liver
42
Q
  • Which clotting factor is involved in the intrinsic pathway and a deficiency results in hemophilia A?
  • Where is this made?
A
  • VIII
  • liver, lung capillaries
43
Q
  • Which clotting factor is involved in the intrinsic pathway and a deficiency results in hemophilia B?
  • Where is this made?
A
  • IX
  • liver
44
Q
  • Which clotting factor marks the beginning of the common pathway?
  • Where is this made?
A
  • X
  • liver
45
Q
  • Which clotting factor functions in the intrinsic pathway and a deficiency results in hemophilia C?
  • Where is this made?
A
  • XI
  • liver
46
Q
  • Which clotting factor is involved in the intrinsic pathway and activates plasmin, initiates clotting in vitro; activation initiates inflammation?
  • Where is this made?
A
  • XII
  • liver
47
Q
  • Which clotting factor cross-links fibrin, forming a strong stable clot?
  • Where is this made?
A
  • XIII
  • liver, bone marrow
48
Q

What are the 2 major types of hemostasis disorders?

A
  • thromboembolic disorders
  • bleeding disorders
49
Q

Which hemostasis disorder results in an undesirable clot formation?

A

thromboembolic disorders

50
Q

Which hemostasis disorder results in abnormalities that prevent normal clot formation?

A

bleeding disorders

51
Q

What hemostasis disorder involves both thromboembolic disorders and bleeding disorders?

A

disseminated intravascular coagulation (DIC)

52
Q

What is required for hemostasis?

A
  • healthy endothelium
  • functioning platelets
  • von willebrand factor
  • adequate clotting/anticlotting facotrs
53
Q

What is the general presentation of bleeding disorders?

A
  • excessive or repetitive bleeding
  • bleeding at unusual sites: petechia, bruising, mucosal bleeding; hemarthroses and deep tissue hematomas; purpura
54
Q

What are the sites of bleeding in the skin for platelet-vascular disorders vs coagulation factor deficiency?

A
  • platelet-vascular disorders: superficial surfaces
  • coagulation factor deficiency: deep tissues
55
Q

What may be present in the mucous membranes in platelet-vascular disorders vs coagulation factor deficiencies?

A
  • platelet-vascular disorder: petechiae, ecchymoses
  • coagulation factor deficiency: hematomas
56
Q

What are some other sites of bleeding besides the skin and mucous membranes in platelet-vascular disorders vs coagulation factor deficiencies?

A
  • platelet-vascular disorder: common in oral, nasal, GI, and GU
  • coagulation factor deficiency: rare
57
Q

Where is the onset of bleeding in platelet-vascular disorders vs coagulation factor deficiencies?

A
  • platelet-vascular: rare
  • coagulation factor deficiencies: joint, muscle, retroperitoneal
58
Q

What are some clinical examples of bleeding d/t platelet vascular disorders vs coagulation factor deficiency?

A
  • platelet vascular disorders: spontaneous or immediately after trauma
  • coagulation factor deficiency: delayed after trauma
59
Q

What are some diagnostic studies you can order for hemostasis disorders?

A
  • CBC
  • PT/INR/aPTT
  • TT
  • metabolic panel
  • D-dimer
  • inhibitor screen
  • lupus anticoagulant/other coagulation factor inhibitors
  • vWF
  • bleeding time
60
Q

What is used in VW disease that determines cellular changes?

A

platelet functional analysis

61
Q

What diagnostic test is reported as INR and evaluated the clotting pathway?

A

PT (protime)

62
Q

What is a normal INR?

A

1

63
Q

If a patient is going into surgery, what always needs to be ordered?

A
  • coagulation panel (PT, INR, aPTT)
64
Q
  • If either PT/PTT is prolonged, what can be ordered that measures the rate of fibrinogen conversion to fibrin, in the presence of thrombin?
  • What does this assess?
A
  • TT (thrombin time)
  • common pathway; sees if theres is a problem below the extrinsic/intrinsic pathways
65
Q

What hemostasis disorder diagnostic test assesses the kidney and liver function?

A

metabolic panel

66
Q

What is used to assess/ID thrombosis in suspected clotting disorders?

A

D-dimer

67
Q

What disorders can you use the D-dimer test for?

A
  • TTP
  • HUS
  • DIC
  • HELLP
  • HIT
68
Q

What is the issue with the D-dimer?

A

good sensitivity, poor specificity

69
Q

What test is where there is a 1 to 1 mix to assess for factor deficiency, so patients are given clotting factors to see if PTT/PT goes back to normal; if no, something is inhibiting the factors

A

inhibitor screen

70
Q

What tests are given to assess if there is a clotting factor issue or if something is inhibiting the factors from working?

A
  • inhibitor screen
  • lupus anticoagulant/other coagulation factor inhibitors
71
Q

What diagnostic test assesses platelet function by finding how long it takes for a patient to stop bleeding?

A

bleeding time

72
Q

What are examples of what could be wrong is PT is elevated, but aPTT is normal?

A
  • liver disease
  • decrease in vitamin K
  • decrease in factor VII
  • anticoagulation drug therapy
73
Q

What are examples of what could be wrong if PT is normal but aPTT is elevated?

A
  • mainly injury related
  • decreased factor VIII, IX, or XI (severe factor XI deficiency)
  • von willebrand disease
  • hemophilia A or B
74
Q

What are examples of what could be wrong if both PT and aPTT are extended?

A
  • decrease in factor I, II, V, or X
  • severe liver disease
  • DIC
    (common factor deficiency)
75
Q

What could be wrong is PT and aPTT are extended but PLT (platelets) are low?

A
  • DIC
  • liver disease
  • lupus anticoagulants
76
Q
  • The finding of a prolonged PT and/or aPTT indicates either a deficiency in (…) or (…), usually an (…) directed at one or more components of the coagulation system
  • These two possibilities can be distinguished by performing a (…), which involves a 1 to 1 mix of the patients plasma and normal plasma
  • If it corrects, what should you do?
  • If it doesn’t correct, what should you do?
A
  • one or more coagulation factors or the presence of an inhibitor, usually an anitbiody
  • inhibitor screen
  • find which clotting factor is wrong/not working
  • find what is inhibiting the clotting factors

Clinical Medicine 2 (9 decks)

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