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Complex Care > Coagulation Disorders > Flashcards

Coagulation Disorders Flashcards

1
Q

What things are needed to clot

A
  1. Liver
  2. Calcium
  3. Phospholipids
  4. Tissue Factor
  5. Platelets
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2
Q

Intrinsic System

A

Most common. Uses elements only found in vessels

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3
Q

Extrinsic System

A

Requires tissue factor which is extrinsic to vessels and released when vessels rupture

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4
Q

What does a PT measure?

A
  1. Measures the time it takes for plasma to clot when exposed to tissue factor (extrinsic pathway)
  2. Measures effectiveness of warfarin
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5
Q

What does warfarin effect?

A

Extrinsic pathway

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6
Q

What is the purpose of an INR?

A

Normalizes the variance in PT values

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7
Q

What is the therapeutic value of INR on Warfarin?

A

2-3

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8
Q

Medications that increase the PT?

A
  1. Abx
  2. Cimetidine
  3. Salicylates
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9
Q

What is a normal PT value?

A

11-13 seconds

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10
Q

Activated Partial Thromboplastin Time (aPTT) measures..

A
  1. The time it takes to clot using the intrinsic clotting system
  2. Heparin therapy
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11
Q

aPTT levels can shift due to…

A

Variables such as disease, medications, physiological states

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12
Q

Why are heparin Anti-Xa labs sometimes preferred?

A

aPTT can shift so some hospitals prefer to use Anti-Xa lab tests for heparin

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13
Q

Normal aPTT times

A

25-38 seconds OR 21-35 seconds

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14
Q

What does an Anti-Xa measure?

A

Measure the intrinsic clotting system

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15
Q

Platelets are produced in… removed by….

A

Platelets are produced in the bone marrow and removed by the spleen

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16
Q

Normal platelet count is

A

150,000-400,000

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17
Q

Thrombocytopenia is

A

LOW PLATELETS

Platelet count below 150,000

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18
Q

Prolonged bleeding occurs when..

A

When platelets are less than 50,000

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19
Q

Spontaneous bleeding occurs when..

A

Platelets are below 20,000

This number is not definite… Could start much lower

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20
Q

Manifestations of thrombocytopenia

A

Epistaxis and gingival bleeding, petechiae, purpura, superficial echymosis, pain/tenderness

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21
Q

Why petechiae?

A

RBC are leaking out of the blood vessels and into the skin

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22
Q

Complications of thrombocytopenia

A

hemorrhage or thrombosis

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23
Q

Thrombocytopenia bleeding precautions

A

Prolonged bleeding after injection just as IM or venipuncture

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24
Q

Diagnostic studied of thrombocytopenia

A

Platelets: less than 150,000
Platelets: less than 50,000 prolonged bleeding
Platelets: less than 20,000 spontaneous bleeding
PT/aPTT: could be normal
Bone marrow examination: megakarycytes on bone marrow biopsy –> thrombocytopenia due to decrease bone marrow production

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25
Q

Diagnostic studies for thrombocytopenia to rule out other diseases

A 
ITP antigen specific assay
PF4 heparin complex (HIT)
Increase lactate dehydrogenase (TTP)
Anemia (TTP)
Bone marrow aspiration (leukemia and anemia)
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26
Q

Heparin MOA

A

inactivates thrombin and factor Xa

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27
Q

Heparin route, onset, duration

A

IV or SubQ
Rapid
Brief

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28
Q

Heparin labs and antidote

A

aPTT

Protamine

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29
Q

Warfarin MOA

A

prevent synthesis of clotting before the vessels

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30
Q

Warfarin route, onset and duration

A

PO
Slow
Prolonged (days)

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31
Q

Warfarin labs and antidote

A

PT(INR)

Vitamin K

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32
Q

Which of the following patients should not take rivaroxaban?

A

Liver failure patient - can lead to further liver injury

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33
Q

Rivarixaban

A

Xa inhibitor
Uses: stroke, PE, VTE
NO testing

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34
Q

Dabigatran

A

Direct thrombin inhibitor
Uses: prevent and manage DVT, stroke, afib
NO testing

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35
Q

Dabigatran antidote

A

Idarucizumab

36
Q

Rivaroxaban (-xaban) antidote

A

Andexanet

37
Q

Neuro s/s with coag disorders

A

change in LOC, aphasia, decrease strength

38
Q

Respiratory s/s with coag disorders

A

SOB, tachypnea, chest pain

39
Q

GI s/s with coag disorders

A

occult bleeding, gastric pain

40
Q

Skin s/s with coag disorders

A

color changes, decrease temp, decrease sensation, decrease pulse

41
Q

Immune Thrombocytopenic Purpura (ITP)

A

Most common aired thrombocytopenia

Autoimmune: antibodies coat platlets –> spleen marks them as foreign –> macrophages destroy

42
Q

Can platelets function with an antibody on them?

A

Yes, they can still function normally but they have a shortened survival rate which leads to low platelets

43
Q

ITP diagnostics

A

ITP antigen assay

44
Q

What causes ITP?

A

H. pylori or viral infection

45
Q

ITP treatment: 1. corticosteroids

A

Used first

Supresses spleen from destroying platelets by suppressing phagocytes and autoimmune antibodies

46
Q

ITP treatment: 2. IVIG

A

Second

For patients that are unresponsive to corticosteroids

47
Q

ITP treatment: 3. Spleenectomy

A
  1. Spleen contains macrophages
  2. Structure enhances the attraction between macrophages and antibody coated platelets
  3. Some antibody synthesis occurs in spleen
  4. Spleen stores 1/3 –> increase circulating platelets
48
Q

ITP treatment: 4. Thrombopoietin Receptor Agonists

A

Romiplostim

increases platelet production

49
Q

ITP treatment: 5. Platelet transfusion

A

if 10,000 or less OR anticipated bleeding before procedure

50
Q

Thrombotic Thrombocytopenia Purpura (TTP)

A

Uncommon
Combination of anemia and thrombocytopenia
ADAMTS13 enzyme breaks down von willebrand factor
Bleeding and clotting at the same time

51
Q

TTP diagnostics

A

ADAMTS13 enzyme activity: low or undetectable
Increase in LDH
Normal Pt/aPTT
Blood smear: schistocytes

52
Q

TTP treatment

A
  1. Treat underlying infection or cause
  2. Plasmapheresis
  3. Corticosteroids
  4. Immunosuppressive therapy (Rituximab)
53
Q

How does Rituximab help with TTP

A

blocks inhibitory ADAMTS13 IgG antibodies

54
Q

Why is administration of platelets contraindicated in patients with TTP?

A

platelets will continue to close and increase the problem

55
Q

What happens if TTP is left untreated?

A

Irreversible renal failure and death

56
Q

When does HIT appear?

A

5-10 days after heparin is started

Can by up to 14

57
Q

HIT

A

immune mediated response where PF4 binds to heparin and creates a positive feedback loop that leads to increased clotting
This decrease the circulating platelets and causes clots
Platelets either drop by 50% or less than 150,000

58
Q

Is bleeding common in patients with HIT?

A

No, because platelets don’t usually drop below 20,000

59
Q

Major complications of HIT

A

venous thrombosis or arterial thrombosis

60
Q

HIT diagnostics

A

Normal PT, aPTT (concerning because a person on heparin should have an increase PTT)
PF4 antibodies
Thrombocytopenia

61
Q

HIT treatment

A
  1. STOP heparin
  2. Give direct thrombin inhibitor
  3. Protamine sulfate to interrupt heparin
  4. Plasmapheresis in severe
  5. Surgically remove clots if needed
62
Q

Disseminated Intravascular Coagulation (DIC)

A

Bleeding and clotting

Exaggerated clotting response –> decreased clotting factors –> hemorrhage

63
Q

Is DIC a disease?

A

DIC is NOT a disease, it is a RESPONSE to a disease
Commonly sepsis
Other: pregnancy, trauma, malignant

64
Q

What is the manifestation for acute DIC?

A

bleeding

65
Q

DIC can be..

A

Acute, subacute, chronic

66
Q

Signs of thrombosis:

A 
Neuro: delirium, coma 
Skin: Ischemia, gangrene 
Renal: oliguria, azotemia 
Resp: ARDS
GI: paralytic ileus
67
Q

Signs of hemorrhage:

A 
Neuro: intracranial bleeding 
Skin: petechiae, ecchymosis 
Renal: hematuria
Resp: dyspnea, hemoptysis 
GI: massive bleeding 
Mucous membranes: epistaxis, gingival bleeding
68
Q

DIC patho: Clotting

A

Clotting activated via release of clotting factor

  1. increase intravascular clots
  2. platelet aggregation increased
  3. fibrin and platelets in capillaries and arterioles
69
Q

DIC patho: Bleeding

A
  1. Fibrin split product accumulate
  2. clotting factors depleted
  3. increased consumption of platelets
70
Q

DIC diagnostics

A
  1. Elevated fibrin split products (FSP)
  2. Decreased fibrinogen and platelets
  3. Prolonged PT, PTT, D-Dimer
71
Q

DIC treatment

A
  1. Treat prior disorder
  2. Monitor for bleeding (no bleeding, no therapy)
  3. Thrombosis (heparin or antithrombin III to prevent clots)
  4. Replacement of blood products (FFP, platelet)
  5. Clot removal
72
Q

Why would you use oral anticoagulants for chronic DIC?

A

Heparin doesn’t work well for chronic DIC

73
Q

When do you use Heparin and Antithrombin III in DIC?

A

Heparin: when the benefits outweigh the risks

Antithrombin III: severe of sudden DIC

74
Q

When do you use replacement blood product in DIC?

A

Serious bleeding, surgery, invasive procedures

75
Q

Teaching for thrombocytopenia

A
  1. Avoid aspirin or other thrombocytopenia meds
  2. Teach s/s of bleeding
  3. Any injections hold pressure for 5-10 minutes
  4. Call doc if nose bleeds longer than 10 mins
  5. AVOID IM injections
  6. Women measure menstrual loss
76
Q

Hemophilia in general is..

A

X-linked recessive disorder
Deficient coag factors leading to prolonged, delay or uncontrolled bleeding because they can’t clot
3 types: A, B, Von Williebrand disease

77
Q

Hemophilia A

A

deficient in factor VIII

Most common

78
Q

Hemophilia B

A

deficient in factor IX

usually males

79
Q

Hemophilia diagnostics

A

Normal PT and platelets
Prolonged PTT
Factor assay-reduction factor VIII, factor IX, vWF

80
Q

Treatment of hemophilia

A
  1. Replacement of deficient clotting factors prophylactically or on demand
  2. DDAVP for mild hemophilia A to stimulate VIII or vWF
  3. Antifibrinolytic - inhibits breaking down of clot by inhibiting plasminogen
81
Q

Complications of replacing clotting factors

A
  1. Development of inhibitor factor VIII and IX
  2. Transfusion transmitted infectious disease
  3. allergic reaction
  4. thrombotic complications
82
Q

Acute interventions for hemophilia

A
  1. Stop bleeding and manage life threatening complications like airway, compartment syndrome or intracranial bleeding
  2. Administer deficient factor
  3. Rest the involved joint, ROM when bleeding stops and weight bearing when swelling is gone
83
Q

Why don’t you want to jump right into weight bearing exercises after acute hemophilia?

A

They should only be after the swelling is gone and as tolerated because it could cause permanent damage to the joint if it is too soon

84
Q

What are some ways to stop bleeding with acute hemophilia?

A

Pressure, ice, gel foam or fibrin foam, topical hemostatic agents (thrombin)

85
Q

Home care for hemophilia

A
  1. Educate on when to come to hospital and when to stay home
  2. Daily oral hygiene
  3. Noncontact sports
  4. Medic alert bracelet
86
Q

What are thing a patient with hemophilia should come to the hospital for?

A
  1. Serve pain in joint that prevents mobility or sleep
  2. head injury
  3. swollen neck or mouth
  4. Abdominal pain
  5. Hematuria
  6. Melena
  7. Skin wounds that need stitches

Complex Care (22 decks)

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