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APEX: Flashcards > Coagulation > Flashcards

Coagulation Flashcards

1
Q

tunica intima

A
  • inner layer of vessel
  • endothelium
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2
Q

tunica media

A
  • middle layer
  • smooth muscle
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3
Q

tunica externa

A
  • outer layer
  • connective tissue
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4
Q

4 steps of hemostasis

A
  1. vascular spasm
  2. formation of platelet plug
  3. coagulation and fibrin formation
  4. fibrinolysis when clot is no longer needed
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5
Q

Collagen

A

procoagulant

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6
Q

vWF

A
  • procoagulant
  • fx: plt adhesion
  • synthesized by vascular endothelium
  • anchors PLT to vessel wall at site of vascular injury
  • carries inactivated factor 8
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7
Q

fibronectin

A
  • procoagulant
  • fx: cell adhesion
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8
Q

protein C

A
  • anticoagulant
  • fx: degrades factor 5a & 8a
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9
Q

protein S

A
  • anticoagulant
  • fx: cofactor for protein C
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10
Q

antithrombin

A
  • anticoagulant
  • fx: inactivates 2a, 9a, 10a , 11a, 12a
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11
Q

tissue pathway factor inhibitor

A
  • anticoagulant
  • fx: inhibits tissue factor
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12
Q

thrombomodulin

A
  • anticoagulant
  • fx: regulates naturally occurring anticoagulants
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13
Q

plasminogen

A
  • fibrinolytic
  • fx: precursor to plasmin
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14
Q

tPA

A
  • fibrinolytic
  • fx: activates plasmin
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15
Q

urokinase

A
  • fibrinolytic
  • fx: activates plasmin
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16
Q

alpha-antiplasmin

A
  • antifibrinolytic
  • fx: inactivates tPA, urokinase
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17
Q

plasminogen activator inhibitor

A

-antifibrinolytic
- fx: inhibits plasmin

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18
Q

thromboxane A2

A

vascular smooth muscle vasoconstrictor

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19
Q

ADP

A

vascular smooth muscle vasoconstrictor

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20
Q

serotonin

A

vascular smooth muscle vasoconstrictor

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21
Q

nitric oxide

A

vascular smooth muscle vasodilator

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22
Q

prostacyclin

A

vascular smooth muscle vasodilator

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23
Q

Where are platelets produced?

A

bone marrow by megakaryocytes

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24
Q

normal PLT count

A

150,000 - 300,000

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25
Q

Lifespan of a PLT

A

8-12 days

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26
Q

PLT cleared by?

A
  1. macrophages in reticuloendothelial system
  2. spleen
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27
Q

External Membrane of PLT

A

Glycoproteins
- adhere to injured endothelium, collagen,
fibrinogen
- GpIb attaches activated PLT to vWF
- GpIIb-IIIa complex links PLT together to form
plug

Phospholipids
- prostaglandin synthesis
- produce thromboxane A2–> activates PLT

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28
Q

Internal component of PLT

A
  1. Actin & myosin = PLT contraction
  2. Thrombosthenin = PLT contraction
  3. ADP = PLT activation & aggregation
  4. Ca+
  5. Fibrin stabilizing factor = crosslinks fibrin
  6. Serotonin = activates nearby PLTs
  7. Growth factor = repair damaged vessel wall
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29
Q

Natural PLT inhibition

A

In the absence of vascular injury, the endothelium inhibits PLT fx by secreting:

  1. Prostaglandin I2 = inhibits vWF, TxA2 activation
  2. Nitric oxide = inhibits TxA2 receptor
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30
Q

PLT receptors

A
  1. GPIb
  2. ADP
  3. TxA2
  4. Thrombin
  5. GPIIb-IIIa
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31
Q

Hemostasis: Vascular spasm

A

Immediately following vascular injury, the vessel contracts to reduce blood flow to area

2 functions:
1. reduces blood loss
2. help procoagulant remain in affected area

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32
Q

Primary hemostasis: Platelet Plug

A
  1. Adhesion
  2. Activation
  3. Aggregation
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33
Q

Adhesion

A
  1. Injury exposes collagen
  2. PLT adhere to collagen via GpIa/IIa & Gp VI
  3. vWF released from endothelium, binds to GpIb, anchors PLTs
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34
Q

Activation

A
  1. Collagen & thrombin activate PLT
  2. PLT release ADP & TXA2 –> nearby PLT active
  3. PLT contract & release fibrinogen, fibronectin, vWF, PLT factor 4, PLT growth factor
  4. PLT swell, misshapen, sticky –> stick to other PLT & injury site

Activated PLT express GpIIb & GpIIIa on surface

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35
Q

Aggregation

A
  • GpIIb/IIIa complex links activated PLT together to form PLT plug
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36
Q

3 steps required to form PLT plug

A
  • Adhesion
  • Activation
  • Aggregation
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37
Q

vWF binds to the PLT during which step?

A

Adhesion

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38
Q

How does the injured vessel initially activate the PLT plug?

A

Endothelial injury exposes collagen. Exposed collagen at the site of vascular injury activates PLT

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39
Q

Clotting factor mnemonic

A

Foolish
People
Try
Climbing
Long
Slopes
After
Christmas
Some
People
Have
Fallen

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40
Q

Factor 1

A

Fibrinogen (liver)

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41
Q

Factor 2

A

Prothrombin (liver)

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42
Q

Factor 3

A

Tissue factor (vascular wall)

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43
Q

Factor 4

A

Calcium ions (diet)

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44
Q

Factor 5

A

Labile factor (liver)

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45
Q

Factor 7

A

Stable factor (liver)

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46
Q

Factor 8

A

Antihemophilic factor (liver)

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47
Q

Factor 9

A

Christmas factor (liver)

48
Q

Factor 10

A

Stuart-Prower factor (liver)

49
Q

Factor 11

A

Plasma thromboplastin antecedent (liver)

50
Q

Factor 12

A

Hageman factor (liver)

51
Q

Factor 13

A

Fibrin stabilizing factor (liver)

52
Q

Coagulation cascade

A
  • Extrinsic = 3, 7 “can be purchased for 37c”
  • Intrinsic = 8, 9, 11, 12 “ if you can’t buy IP for $12, can buy for $11.98
  • Final common = 1, 2, 5, 10, 13 “can be purchased at 5 & dime (10) for 1 or 2 dollars on 13th of month”
53
Q

Which coagulation factors are vitamin K dependent?

A

II, VII, IX, X

54
Q

Which clotting factors are a part of the extrinsic pathway?

A

III, VII

55
Q

Extrinsic pathway measured by what lab?

A

PT, INR

56
Q

What drug inhibits intrinsic pathway?

A

warfarin

57
Q

How fast can a clot form via the extrinsic pathway?

A

~15 sec

58
Q

Intrinsic pathway measured by what lab?

A

PTT, ACT

59
Q

Intrinsic pathway inhibited by what drug?

A

heparin

60
Q

What is the first factor to be depleted in the patient w/ vitamin K deficiency?

A

factor VII (also applies to liver failure & pt on coumadin)

61
Q

4 mechanisms that counterbalance blot formation

A
  • Vasodilation & washout of ADP & TXA2
  • Antithrombin inactivating thrombin
  • Tissue factor pathway inhibitor neutralizes tissue factor
  • Release of protein C & S
62
Q

2 enzymes that convert plasminogen to plasmin

A
  • tPa
  • urokinase
63
Q

What 2 enzyme inhibitors turn off the fibrinolytic process?

A
  • tPa inhibitor
  • A2 antiplasmin
64
Q

How are plasmin activators used therapeutically?

A

they help dissolve thrombi to restore blood flow

65
Q

Fibrinolysis

A
66
Q

aPTT

A
  • Activated Partial Thromboplastin Time
  • Assesses intrinsic & common pathways
  • Monitors heparin
  • ## Normal = 25-32 sec
67
Q

PT

A
  • Prothrombin time
  • Monitors warfarin
  • Normal = 12-14 sec
68
Q

INR

A
  • International Normalization Ratio
  • Normal = ~1
  • Target for coumadin = 2-3 x control
69
Q

Activated clotting time

A
  • Guides heparin dosing
  • Normal = 90-120 sec
  • > 400 for CPB
70
Q

PLT count

A
  • Monitors #, not function
  • Normal = 150,000 - 300,000
71
Q

Bleeding time

A
  • Monitors PLT function
  • Evaluates PLT plug
  • Normal = 2-10 min
72
Q

D- Dimer

A
  • Monitors fibrinolysis
  • Normal = < 500 mg/ml
73
Q

Best predictor of bleeding during surgery

A

H&P

74
Q

TEG components

A
75
Q

R time

A
  • time to begin forming clot
  • normal = 6-8 min
  • problem = coags
  • Tx = FFP
76
Q

K time

A
  • Time until clot has achieved fixed strength
  • Normal = 3-7 min
  • Problem = fibrinogen
  • Tx = cryo
77
Q

Alpha angle

A
  • Speed of fibrin accumulation
  • Normal = 50-60 degrees
  • Problem = fibrinogenn
  • Tx = Cryo
78
Q

Maximum amplitude

A
  • Highest vertical amplitude on TEG
  • Measure clot strength
  • Normal = 50-60 mm
  • Problem = PLT
  • Tx = PLT +/- DDAVP
79
Q

A60

A
  • Height of vertical amplitude 60 minutes after maximum amplitude
  • Normal = 5
  • Problem = excess fibrinolysis
  • Tx = TXA, aminocaproic acid
80
Q
A

Normal

81
Q
A

factor deficiency anticoagulation

82
Q
A

impaired PLT number or function

83
Q
A

primary fibrinolysis

84
Q
A

hypercoagulation

85
Q
A

DIC stage 1 (hypercoagulable)

86
Q
A

DIC stage 2 (hypocoagulable)

87
Q

Heparin inhibits which pathway?

A

intrinsic & final common pathway

88
Q

Heparin MOA

A
  • Inhibits intrinsic & final common pathways
  • binds to AT3 & accelerates its anticoagulant ability
  • neutralizes thrombin & activates factors 9, 10 ,11, 12
89
Q

CPB dose for heparin

A

300-400 U/kg

90
Q

therapeutic heparizination occurs when aPTT is:

A

1.5 - 2.5 x normal ( normal = 25-35 sec)

91
Q

Can a pregnant patient receive IV heparin?

A

yes, it doesn’t cross placenta

92
Q

Protamine

A
  • derived from salmon sperm
  • positively charged protamine & negatively charged heparin create neutralization
  • dose = 1 mg for every 100 U heparin
93
Q

Protamine SE

A
  • Hypotension (histamine); push slow
  • Pulmonary HTN ( TxA2 & 5HT release)
  • Allergic reaction (previous sensitization to NPH, fish allergy, vasectomy)
94
Q

Coumadin inhibits factors:

A

2, 7, 9, 10, protein C & S

95
Q

Warfarin

A
  • Inhibits vitamin K dependent factors (2, 7, 9, 10, protein C & S)
  • Highly protein bound
  • Monitored w/ PT/INR
  • Antidote = Vit K, FFP, recombinant VIIa, prothromin complex concentrate
96
Q

Risk factors for vit K deficiency

A
  • Poor dietary intake
  • ABX therapy kills off GI flora & reduces Vit K synthesis
  • Malabsorption d/t obstructive biliary tract dz
  • Hepatocellular dz
  • Neonates do not have intestinal flora that synthesizes vit K
97
Q

Clopidogrel

A
  • ADP receptor inhibitor
  • Stop 5-7 days preop
98
Q

Ticlopidine

A
  • ADP receptor inhibitor
  • Stop 14 days preop
99
Q

Prasurgel

A
  • ADP receptor inhibitor
  • Stop 7-10 days preop
100
Q

Ticagreclor

A
  • ADP receptor inhibitor
  • Stop 5-7 days preop
101
Q

COX inhibitor MOA

A
  • prevent PLT aggregation by blocking cyclooxygenase 1
  • stop conversion of arachidonic acid to prostaglandins & ultimately thromboxane A2
102
Q

Aspirin

A
  • COX inhibitor
  • Stop 7 days preop
103
Q

NSAIDs

A
  • COX inhibitor
  • Stop 1-2 days preop
104
Q

Heparin

A
  • Unfractioned - stop 6 hrs preop
  • LWWH - stop 1-2 days preop
105
Q

Warfarin

A
  • Vit K antagonist
  • Stop 2 -4 days preop
106
Q

Antifibrinolytics

A
  • Stop conversion of plasminogen to plasmin
  • promote clot formation
  • TXA, aminocaproic acid
107
Q

Fibrinolytics

A
  • conversion of plasminogen to plasmin
  • break down clots
  • tPA, urokinase, streptokinase, reteplase, alteplase
108
Q

tPA

A
  • Plasminogen activator
  • Stop 1 hr preop
109
Q

vWF Dz

A
  • Most common inherited d/o of PLT fx
  • Normal PLT count, Plt dysfunction
  • Increased PTT & bleeding time
  • Tx:
    1. DDAVP - stimulates release of vWF & increases factor 8 activity
    2. Cryo (8,13, fibrinogen, vWF)
    3. FFP (all clotting factors)
    4. Purified 8-vWF
110
Q

Hemophilia A

A
  • X linked
  • Factor 8 deficiency
  • Prolonged PTT
  • Tx: factor 8 conc, FFP, cryo
111
Q

Hemophilia B

A

factor 9 deficiency

112
Q

DIC

A
  • Disorganized clotting & fibrinolysis
  • Thrombin formation creates microvascular clots that impair tissue perfusion causing hypoxia & acidosis
  • Activates anticoagulant system leading to consumption of coag factors, fibrinogen, & PLT
  • S/S
    1. Ecchymosis
    2. Petechiae
    3. Mucosal bleeding
    4. Bleeding at IV site
  • High risk = sepsis, OB, malignancy, preeclampsia, placental abruption, AFE
  • Tx = IVFs, FFP, PLTs, Cryo, IV heparin, LMWH
113
Q

Protein C & S deficiency results in:

A
  • hypercoagulability
  • thrombosis
114
Q

Coagulation d/o tx w/ desmopressin

A
  • vWB Type I > II
  • Hemophilia A
115
Q

MOA Desmopressin/DDAVP

A

stimulates release of vWF & increases factor 8 activity

APEX: Flashcards (13 decks)

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