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Clinical Science > Clotting and Bleeding > Flashcards

Clotting and Bleeding Flashcards

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1
Q

Primary Hemostasis

A
  1. arterial vasoconstriction, to reduce blood flow to the injury site. 2. VWF released, the wall becomes “sticky” 3. Platelet adhesion- initial platelet is friable and can be washed away one vasorelaxation occurs.
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2
Q

Secondary Hemostasis

A

involves and intrinsic and extrinsic pathway

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3
Q

Intrinsic pathway

A

this is contact activation. when blood hits exposed collagen, it activates factor XII

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4
Q

Extrinsic Pathway

A

the damaged tissue itself releases tissue factors, which complex with factor VII

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5
Q

The work horse of the coag cascade

A

Thrombin Activates 5, 7, 8, 11, 13

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6
Q

Vitamin K dependent clotting factors

A

II VII IX X

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7
Q

Factor I

A

Fibrinogen

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8
Q

Factor II

A

Prothrombin

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9
Q

Factor III

A

Tissue factor, or thromboplastin

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10
Q

Factor VIII

A

Anti-hemophillic factor

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11
Q

Factor IX

A

Christmas factor

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12
Q

Bleeding disorders and genetics

A

30-40% of patients with Hemophilia A or B do not have a family history!

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13
Q

Signs indicating it is a platelet defect

A

Mucocutaneous bleeding of oral cavity, nasal, GI, GU Increased bleeding after cuts Small areas of superficial bleeding Variable amounts of bleeding after major surgery immediate

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14
Q

Signs indicating it is a clotting defect

A

Deep tissue bleeding (joint and muscle) Large hematomas Can be delayed bleeding post-surgery

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15
Q

Platelet disorders

A

Von Willebrand disease (most common) Immune thrombocytopenia

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16
Q

Clotting deficiencies

A

Factor VIII (Hemophilia A) Factor IX (Hemophilia B) Factor XI (Hemophilia C)

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17
Q

Inherited coagulation disorders

A

Increased propensity for forming blood clots. Not all patients with a venous or arterial blood clot will have a coagulation disorder, but can be a factor in 50% of patients presenting before age 40. Risk for clots can also be increased in pregnancy, cancer and estrogen therapy.

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18
Q

Antithrombin

A

alpha-2 globulin made in the liver functions as a negative feedback moderator- is an anticoagulant. Works on Thrombin and factor Xa. Deficiency increases coagulation (if this goes unchecked, can deplete all clotting factors and eventually will result in uncontrollable bleeding).

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19
Q

decreased antithrombin manifestations

A

DVT Pulmonary embolism Phlebitis Heparin resistance getting clots early in age

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20
Q

Protein C

A

Anticoagulant, synthesized in the liver

•inhibits factor Va and factor VIIIa

Vitamin K dependent

Test with Protein S

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21
Q

Protein S

A

anticoagulant, made in the liver

•co-factor to protein C and enhances the function of Protein C
vitamin K dependent

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22
Q

Protein C/S defeciency manifestation

A
  • Venous thromboembolism (VTE) → increased risk 7 fold!
  • Disseminated Intravascular Coagulation
  • Neonatal purpura fulminans
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23
Q

Factor V Leiden

A

inherited, mutated form of factor V

Doesnt allow protein C to cleave at normal site, so it stays in circulation longer, increasing coagulation

Test indicated in pts who have had a thrombotic event without any other predisposing factors, if pt has a strong family hx of thrombosis, DVT when pregnant or on OCP

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24
Q

Fibrinogen

A

clotting factor, produced in the liver

is converted to fibrin via Thrombin

Is an acute phase reactant

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25
Q

Dysfibrinogenemia

A

§Dysfunctional fibrinogen, bleeding or thrombosis occurs, poor wound healing

26
Q

§Hypofibrinogenemia

A

Reduced fibrinogen, usually mild bleeding

27
Q

§Hypodysfibrinogenemia

A

Reduced AND dysfunctional fibrinogen, bleeding or thrombosis

28
Q

§Afibrinogenemia

A

§Rare genetic condition resulting in complete lack of fibrinogen (↑ in consanguinity)
results in mild-severe bleeding

29
Q

Bleeding time

A

test that can be useful in evaluating platelet function, but is not super reproducible

An incision 1mm deep x 10 mm long is made into the skin, and a stopwatch records the time. Every 30 seconds, a filter paper is applied over wound. Once the filter paper no longer absorbs blood, the test time is recorded.

30
Q

Normal bleeding time

A

1-9 minutes

31
Q

Abnormal bleeding time

A

9-15 minutes indicative of platelet dysfunction

>15 minutes is critical

32
Q

Increased bleeding time

A

due to : decreased platelet count

fibrinogen defeciency

VW disease

medications (NSAIDs)

Liver failure

Leukemias

33
Q

Prothrombin time/
International Normalized Ratio (PT/INR)

A
  • “ProTime” or “INR”
  • Useful in the evaluation of the factors I (fibrinogen), II (prothrombin), V, VII, and X ( i.e., the extrinsic system and common pathway).
  • Tissue factor is added to the blood sample and the time that it takes to clot is measured.

•If these clotting factors are deficient, the Prothrombin Time is prolonged…takes more time to clot
•Primarily used to monitor patients on warfarin therapy
MEASURES THE EXTRINSIC PATHWAY

34
Q

PT/INR normal

A

PT: 11.0-12.5 seconds

INR: 0.8-1.1

Critical when INR > 5

35
Q

Ideal INR for DVT/treatment

A

2-3

36
Q

Partial Thromboplastin Time

A

commonly used to evaluate the patient who is on heparin therapy for anticoagulation (heparin inactivates Factor II

•The PTT evaluates factors I, II, V, VIII, IX, X, XI, and XII –> the intrinsic pathway

37
Q

Activated PTT

A

aPTT- activator is added to a PTT test. Basically decreases clotting time in half

38
Q

PTT/aPTT normal

A

aPTT: 30-40 seconds

PTT: 60-70 seconds

39
Q

Thrombin time

A

assesses the amount of fibrin formation that is occurring

Normal less than 20 seconds, but this depends on the lab

thrombin time is increased in congenital or impaired hypofibrinogemia and DIC

40
Q

prefferred INR for orthopedic surgery

A
41
Q

preferred INR for A fib

A

2-3

42
Q

preferred INR for prosthetic valve prophylaxis

A

2.5-3.5

43
Q

Prostate Specific Antigen

A

a glycoprotein expressed in normal and neoplastic prostate tissue, but usually expressed in higher concentration in prostate cancer cells.

Not specific though, as more frequently elevated in hyperplasia and inflammation of the prostate

44
Q

PSA normal

A

•0.00-4.00 ng/ml

45
Q

% of men with prostate ca who have a normal PSA

A
46
Q

PSA velocity

A

Some clinicians use this instead of PSA alone
PSA velocity > 0.75 ng/mL/year can be correlated with prostate cancer. Serial, annual measurement used x 3 years.

47
Q

free PSA

A

Another measurement for prostate ca, possibly more accurate than PSA.
•ratio of free-to-total PSA is reduced in men with prostate cancer.

48
Q

CA125

A

•most often present in ovarian carcinoma- but levels can vary in different cell types

•Due to immensely low specificity and sensitivity, this test is not recommended as a screening tool currently
women with ovarian cancer will have their CA125 levels measured to evaluate therapy.

CA125 can also be elevated in breast, colon, liver, pancreatic and lung cancer. Can also be high in systemic illnesses like infection and autoimmune.

49
Q

OVA-1

A

test that uses 5 biomarkers to evaluate if an adnexal mass is cancerous before surgery, identify if a pt with an ovarian mass is high risk, and identify cancers that were previously missed with CA125

50
Q

Beta-2 macroglobulin

A

1 of the 5 biomarkers in OVA-1

is

51
Q

CA 125II

A

1 of the 5 biomarkers of OVA-1

2nd generation CA125

52
Q

Apolipoprotein A1

A

1 of the 5 biomarkers in OVA-1

◦involved in cholesterol transport but has some role in tumor suppression
decreased in ovarian CA

53
Q

Prealbumin

A

1 of the 5 biomarkers in OVA-1

◦decreases with tumor burden due to metabolic changes that occur in cancer

54
Q

Transferrin

A

1 of the 5 biomarkers in OVA-1

down-regulated in ovarian cancer

55
Q

Carcinoembryonic antigen

A

CEA

•CEA is a protein normally found in fetal tissue, levels usually disappear after birth, but may be present in colon

  • CEA is used to monitor response to chemotherapy or post-surgery in colon cancer
  • Serial measurements recommended to detect recurrence of tumors
  • CEA not recommended as a screening test as sensitivity can vary from 4% (breast cancer) to 70+% (colon and rectal cancer)

CEA can also be elevated in benign states- GI infection/inflammation and smoking.
•

56
Q

Cancer Antigen 19-9

A

CA19-9 is present in epithelial tissues of many organs

•most frequently used to monitor disease response to treatment with pancreatic cancer.

  • not recommended as a screening test for pancreatic or colon cancer
  • Preoperative levels correlate with outcome
  • Rising levels correspond with recurrence and shorter survival time.
57
Q

Cancer Antigen 15-3

A
  • Most often used in breast cancer patients and most widely used serum marker in diagnosis of breast cancer
  • Levels correspond with progression or regression of disease
  • Higher levels correspond with greater tumor size or disease burden/stage and highest levels tend to occur with metastasis to bone or liver

Does have low specificity and sensitivity

58
Q

CA 27-29

A

variation of CA 15-3

can also be used in Breast cancer marking

59
Q

Alpha-fetoprotein

A

•AFP is produced in fetal liver, yolk sac, and GI tract, therefore infants can have very high levels

  • In adults, AFP is most commonly used marker for hepatocellular cancer
  • AFP levels do not correlate well with size of tumor, stage of cancer or prognosis of disease.
  • Values over 500 mcg/L in a patient at high-risk for hepatocellular carcinoma is nearly diagnostic of the disease (normal value in non-pregnant patient < 40mcg/L)
  • High false negative rate- serum levels are normal in 40% HCC patients
60
Q

Serum calcitonin

A

used in detection of Medullary Thyroid Carcinoma (MTC)- production of calcitonin is characteristic of MTC.

•elevated calcitonin level correlates with tumor size pre-operatively

Calcitonin can also be elevated in other cancers that have bony mets, and in non ca diseases of the thyroid

Clinical Science (15 decks)

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