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Heme > Approach to the Bleeding Patient > Flashcards

Approach to the Bleeding Patient Flashcards

1
Q

How do you calculate INR?

A

PT (patient) divided by PT (mean normal)
Raised to exponent (ISI)

PT=prothrombin time

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2
Q

What are 5 ways liver disease affects clotting?

A 
Vitamin K deficiency
Thrombocytopenia
Decreased production of clotting factors
Dysfibrinogenemia
Increased fibrinolytic activity
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3
Q

What are the results of inappropriate thrombin generation in DIC?

A
  1. thrombocytopenia
  2. drop in fibrinogen
  3. decrease in factors (particularly V/VIII)
  4. Low levels of antithrombin III and Protein C
  5. Secondary fibrinolysis
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4
Q

Causes of DIC?

A

Infection
Malignancy
Obstetric complications

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5
Q

Treatment of DIC

A
  1. Identify and treat the underlying cause
  2. Fresh frozen plasma
  3. Platelets
  4. Antithrombin III concentrates
  5. Activated protein C concentrates
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6
Q

What are 5 symptoms of Thrombotic thrombocytopenic Purpura (TTP)?

A
  1. Microangiopathic hemolytic anemia
  2. Thrombocytopenia
  3. Mental status changes
  4. Renal insufficiency
  5. Fever
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7
Q

What are 6 diagnostic indicators of TTP?

A
  1. Schizocytes on PBS
  2. Thrombocytopenia
  3. Markedly elevated LDH
  4. Increased indirect bilirubin
  5. Decreased ADAMTS13
  6. Antibody to ADAMTS13
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8
Q

Treatment of TTP?

A

Plasma exchange
Fresh frozen plasma
Steroids
Rituximab

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9
Q

Do NOT treat TTP with:

A

platelets

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10
Q

Differential diagnosis of microangiopathic hemolytic anemia and thrombocytopenia?

A 
TTP
Hemolytic uremic syndrome (HUS)
HELLP syndrome
DIC
SLE
Malignant hypertension
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11
Q

If there is a low platelet count + bleeding, what are the 3 lab tests you are going to order?

A
  1. BM examination (production prob)
  2. Platelet Abs (ITP)
  3. Screening test for DIC
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12
Q

If there is a normal platelet count + bleeding, what are the 4 tests you want to order?

A
  1. PT and PTT (clotting factors)
  2. Platelet aggregation studies with ADP, epi, collagen
  3. Other platelet tests (adhesion molecules)
  4. vWF and Factor VIII assays
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13
Q

What lab test distinguishes between vWF disease and hemophilia?

A

vWF assay: both will have low Factor 8 but vWF disease will also have low vWF

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14
Q

What is a correction/inhibitors test? Explain the results

A

pt plasma mixed with normal plasma and do a PPT

normal PPT= could be factor deficiency
abnormal PPT = patient has an inhibitor (Ab against a factor)

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15
Q

T of F: Aspirin will affect a platelet function analysis

A

T

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16
Q

What can cause a long platelet function analysis performed with epi and ADP?

A

vWF disease or platelet dysfunction

17
Q

What test do you perform to check if anti-platelet drugs are working?

A

platelet aggregation study

18
Q

What is the therapeutic range for INR?

A

2-2.5

19
Q

Why do we use INRs?

A

A way to compare bleeding across all labs

human brain vs rabbit brain used for thromboplastin

20
Q

What is the definition of disseminated Intravascular Coagulation?

A

inappropriate generation of thrombin

21
Q

For a pt with DIC will the following be normal, low, or high?

fibrinogen 
PTT
PT
platelet count
factor 5 and 8
anti-thrombin 3
protein C
fibrinolysis
A 
fibrinogen: low
PTT: high
PT: high
platelet count: low
factor 5 and 8: low
anti-thrombin 3: low
protein C: low
fibrinolysis: high
22
Q

Why do you see peripheral gangrene in DIC?

A

clotting off capillaries

23
Q

T or F: in DIC, pt can bleed and get thrombosis at the same time

A

T

24
Q

What treatment for DIC directly blocks the action of thrombin?

A

anti-thrombin 3 concentrate

25
Q

Who is most likely to get TTP?

A

women 20-40s

26
Q

What are the 3 signs/symp of TTP?

A

MAHA
thrombocytopenia
mental status changes (TIA, stroke, headache, irritable)

27
Q

What is the pathogenesis of TTP?

A

Ab to ADAMTS13 = vWF multimer does not get cleaved–> causes platelet aggregates in microcirculation –> RBCs try to get past them and are fragmented (schistiocytes formed) –> more and more capillary beds are involved

28
Q

What is the function of ADAMTS31?

A

protease that cleaves vWF multimers to be the correct size

29
Q

T or F: the presnece of the ADAMTS31 Ab is the lab value you need to confirm Dx and begin Tx.

A

F: if you wait until you get the Ab results the pt will be dead

30
Q

What is the most effective Tx for TTP?

A

plasma exchange + immunosupressants bc 40% will relapse

31
Q

Why do you not give a TTP pt platelets?

A

they will cause them to stroke

Heme (38 decks)

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