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SU18: Internal med final > Bleeding & Hypercoagulable Disorders > Flashcards

Bleeding & Hypercoagulable Disorders Flashcards

1
Q

T/F: congenital bleeding disorders have a lot of variance in penetrance presentation thus affecting the severity of the disorder

A

true

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2
Q

what happens after a vessel is injured?

A
  1. vessel spasm (constricts)
  2. platelets adhere to injury site and aggregate to form plug
  3. formation of insoluble fibrin strands and coagulation
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3
Q

how soon after injury does the vessel spasm and platelets adhere to injury site and aggregate to form plug?

A

immediate

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4
Q

how soon after a platelet plug is formed does the formation of insoluble fibrin strands and coagulation occur?

A

several hours or longer

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5
Q

what will the platelet count tell you?

A

will only tell you how many platelets that pt has

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6
Q

what happens if pt’s platelet count is <50,000?

A

pt will bleed excessively with minor trauma

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7
Q

what happens if pt’s platelet count is <20,000?

A

pt will have spontaneous bleeding

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8
Q

causes of acquired platelet disorders

A
  • bone marrow suppression
  • alcoholism
  • WBC cancers
  • anti-platelet drugs
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9
Q

which anti-platelet drug should pts with acquired platelet disorders avoid?

A

Aspirin

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10
Q

Aspirin

A

IRREVERSIBLE cyclooxygenase inhibitor

*won’t allow formation of Thromboxane A2

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11
Q

fxns of thromboxane A2 (COX-1)

A
  • platelet aggregation

- vasoconstriction

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12
Q

what effect does Aspirin have on prostacyclins?

A

none, does not inhibit platelets

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13
Q

effect NSAIDs have on pts with acquired platelet disorders

A

decrease platelet aggregation but is REVERSIBLE

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14
Q

if pt stops taking NSAIDs, how many hours would it take for platelets to gain back their ability of sticking to each other?

A

in 36-48 hrs

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15
Q

clopidogrel

A

anti-platelet drug that is an ADP receptor inhibitor

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16
Q

what is the most common classification of oral anti-platelet drugs?

A

ADP receptor inhibitors

*Aspirin

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17
Q

tirofiban

A

anti-platelet drug that is a glycoprotein llb/llla inhibitors
*glycoprotein helps platelets stick together

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18
Q

are ADP receptor inhibitors reversible?

A

no, they’re irreversible

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19
Q

lifespan of platelet

A

10-14 days

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20
Q

should you get a platelet count on pts taking anti-platelet drugs?

A
  • no, test will show pt has normal number of platelets

- don’t tell you how well the platelets are fxning

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21
Q

should you be worried about pts on anti-platelet therapy bleeding on you during surgery?

A

no, bleeding typically insignificant even with dual anti-platelet therapy (Aspirin + clopidogrel)

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22
Q

should pts stop taking their anti-platelet drugs before coming to their dental appt?

A

no

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23
Q

acquired coagulation disorders can be caused by

A
  • liver disease

- anticoagulant drugs

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24
Q

what is the correlation between liver disease and acquiring a coagulation disorder?

A

vitamin-k dependent clotting factors are produced in the liver

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25
Q

which clotting factors are made in the liver?

A
  • VII
  • IX
  • X
  • II (prothrombin)
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26
Q

which anti-coagulant drug is used in dialysis pts the day of dialysis so blood doesn’t clot up the machine?

A

heparin

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27
Q

which anticoagulant drugs are more stable in the blood and doesn’t need as much monitoring as coumadin but is costly

A
  • direct thrombin inhibitors (dabigatran)

- factor Xa inhibitors (rivaroxaban, betrixaban)

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28
Q

2-3 INR is the recommended therapeutic range for warfarin therapy in which diseases?

A
  • treatment of deep vein thrombosis and pulmonary embolism
  • prevention of systemic embolism
  • bioprosthetic heart valves
  • acute MI
  • a-fib
  • valvular heart disease
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29
Q

2.5-3.5 INR is the recommended therapeutic range for warfarin therapy for what?

A
  • mechanical prosthetic heart valve

- prevention of recurrent MI

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30
Q

what is used to monitor vitamin-K antagonists?

A

INR

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31
Q

INR for minor oral surgery/invasive dentistry?

A

<3.0

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32
Q

pre-operative INR should be drawn how many hours before appt?

A

48 hours

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33
Q

how long does it take to modify warfarin dosage if INR not in therapeutic range or is too high for treatment?

A

3-5 days

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34
Q

is the newer oral anticoagulant drugs monitored with INR?

A

no, work by different mechanism

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35
Q

are the newer oral anticoagulant drugs more or less stable in the blood?

A

more stable

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36
Q

what is the dosage for the newer oral anticoagulant drugs before a surgical procedure?

A

1 pre-op dose and 1 post-op dose

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37
Q

what type of pts will need to have more pre-op doses of the newer oral anticoagulant drugs before a surgical procedure?

A

pts with renal impairment

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38
Q

what are some additional bleeding control by local measures?

A

collaplug + thrombin +/- primary closure

39
Q

what should you do if the bleeding does not stop with local measures?

A
  • contact hematologist

- can give IV infusion

40
Q

what does the IV infusion contain?

A
  • vitamin K
  • fresh frozen plasma
  • prothrombin concentrate
41
Q

what is the analgesic of choice for pts with acquired bleeding disorder?

A

Tylenol

42
Q

which analgesic should be avoided in pts with acquired bleeding disorder?

A

NSAIDs may potentiate bleeding

43
Q

additional guidelines for pts with acquired bleeding disorder undergoing surgery

A
  • strict post-op instructions to promote clotting
  • no Friday surgery
  • early AM surgery
44
Q

what is the most common congenital bleeding disorder?

A

von Willebrand disease

45
Q

what percent of coagulation disorders are Hemophilia A?

A

80%

46
Q

T/F: congenital bleeding disorders are more common than acquired bleeding disorders

A

false

47
Q

T/F: Hemophilia B is more common than Hemophilia A

A

false

Hem A > Hem B

48
Q

von Willebrand disease

A
  • genetic disorder

- missing or defective von Willebrand factor (a clotting protein)

49
Q

what percent of US population has von Willebrand disease?

A

1%

50
Q

T/F: von Willebrand disease equally occurs in men and women

A

true

51
Q

common syms of von Willebrand disease

A
  • frequent nosebleeds
  • easy bruising
  • excessive bleeding during and after invasive procedures (EXT)
52
Q

what is another common sym present in women with von Willebrand disease

A

heavy bleeding during periods and can have bad hemorrhages during child birth

53
Q

von Willebrand factor fxn

A
  • binds platelets to exposed collagen (adhesion)

- binds platelets to platelets (aggregation)

54
Q

what does von Willebrand factor bind to?

A

circulating factor VIII

55
Q

what happens to the unbound factor VIII?

A

it gets destroyed

56
Q

main fxn of factor VIII?

A

help factor IX convert to factor X

57
Q

what happens if there is no factor VIII?

A
  • whole left side of cascade gets wiped out

- coagulation won’t occur properly

58
Q

how many types of von Willebrand disease are there?

A

3

59
Q

type 1 von Willebrand disease

A

low von Willebrand factor levels (quantitative issue)

60
Q

how many von Willebrand disease pts have type 1?

A

60-80%

61
Q

syms of type 1 von Willebrand disease pts

A

mild thus most easily managed

62
Q

which is the most common von Willebrand disease type?

A

type 1

63
Q

type 2 von Willebrand disease

A

normal von Willebrand factor levels but doesn’t work properly (qualitative issue)

64
Q

how many von Willebrand disease pts have type 2?

A

15-30%

65
Q

syms of type 2 von Willebrand disease pts

A

mild-moderate

66
Q

type 3 von Willebrand disease

A

little or no von Willebrand factor (quantitative issue)

67
Q

how many von Willebrand disease pts have type 3?

A

5-10%

68
Q

syms of type 3 von Willebrand disease pts

A

severe

*can get spontaneous bleeding into joints and need immediate factor replacement

69
Q

syms of type 3 von Willebrand disease pts are similar to what?

A

Hemophilia pts

70
Q

med management of von Willebrand disease

A

depends on type of vWD and severity of syms

71
Q

what lab test correlated with the bleeding syms of vWD?

A

none

72
Q

drugs for pts with vWD

A
  • desmopressin (DDAVP)
  • replacement therapy with vWF-containing concentrates
  • antifibrinolytic therapy
73
Q

desmopressing (DDAVP)

A

stimulates release of vWF from endothelial cells

74
Q

what does DDAVP increase?

A

increases plasma factor VIII and vWF levels

75
Q

DDAVP works well for what type of vWD?

A

type 1

76
Q

can type 2 vWD pts take DDAVP?

A

no, doesn’t work well… will increase tons of defective vWF instead

77
Q

vWF replacement is for which type of vWD?

A
  • severe type 1
  • type 2
  • type 3
78
Q

what is considered severe type 1 vWD?

A

when there is no response to desmopressin

79
Q

antifibrinolytic therapy

A

prevent the dissolution of the hemostatic plug

80
Q

most 2 common anti-fibrinolytic drugs?

A
  • aminocaproic acid

- tranexamic acid

81
Q

dental management for surgical procedures on pts with vWD

A
  • consult with hematologist for perioperative management
82
Q

what is the pre-op drug used to manage type 1 and most type 2 VWD pts for surgery?

A

desmopressin

83
Q

what is the post-op drug used to manage type 1 and most type 2 VWD pts for surgery?

A

anti-fibrinolytic therapy

84
Q

what is the analgesia used to manage type 1 and most type 2 VWD pts for surgery?

A

acetaminophen or acetaminophen-opioid combos

85
Q

can vWD pts take NSAIDs for analgesia post-surgery?

A

NO

86
Q

Hemophilia A

A

inherited factor VIII deficiency

87
Q

normal homeostasis requires at least what percent of factor VIII activity in Hem A pts?

A

at least 30%

88
Q

Hem A pts will be symptomatic with what percent of factor VIII activity?

A

<5%

89
Q

what will happen if Hem A pts have <1% of factor VIII activity?

A

severe/spontaneous bleeding

90
Q

txtment for mild hemophilia

A

DDAVP

91
Q

txtment for severe hemophilia

A

factor replacement

92
Q

dental management of Hem A pts for surgical procedures

A
  • consult hematologist to direct perioperative course

- local measures for hemostatic control

93
Q

drugs for pts with Hem A

A
  • DDAVP
  • factor replacement
  • anti-fibrinolytics
94
Q

analgesia for Hem A pts

A

Tylenol

SU18: Internal med final (25 decks)

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