Diagnosis and Management of Bleeding/Clotting Disorders

Question 1

What are key findings in the patient history that may point towards a platelet disorder?

Answer 1

Mucosal bleeding = nose bleeds and gingival bleeds

Question 2

What is a key finding in an adult woman’s history that may point towards a bleeding disorder?

Answer 2

Very heavy menstrual bleeding

ex. change pad/tampon every hour

Question 3

What is a key finding in the patient history that may point towards a coagulation disorder?

Answer 3

Spontaneous hemarthroses

Question 4

Primary disorders

Answer 4

Platelets

Question 5

Secondary disorders

Answer 5

Coagulation cascade proteins/factors

Question 6

What 3 things do you want to measure if Von Willebrand Disease is suspected?

Answer 6

vWF antigen
vWF cofactor
Factor VIII

Question 7

What type of vWF Disease has decreased vWF and normal factor VIII?

Answer 7

Type 1

Question 8

How are Types 1, 2A and 2B Von Willebrand Disease inherited?

Answer 8

Autosomal DOMINANT

Question 9

What type of vWF Disease has severely decreased vWF and decreased factor VIII?

Answer 9

Type 3

Question 10

What is the treatment for minor bleeding associated with Von Willebrand Disease?

Answer 10

Desmopressin - allows release of vWF

Question 11

Desmopressin treats mild Von Willebrand Disease. What are its side effects?

Answer 11

Hyponatremia
Flushing
Hypotension

Question 12

What does Desmopressin treat and how?

Answer 12

Mild bleeding due to Von Willebrand Disease

- Allows release of vWF

Question 13

What is the treatment for major bleeding associated with Von Willebrand Disease?

Answer 13

Plasma derived or recombinant vWF

Question 14

Disorders of secondary hemostasis have a ____ PT and/or PTT

Answer 14

PROLONGED

Question 15

Hemophilia A

Answer 15

Decrease in Factor VIII

Question 16

How is Hemophilia A inherited?

Answer 16

X-linked Recessive

Question 17

Hemophilia B

Answer 17

Decrease in Factor IX

Question 18

What type of testing with Hemophilias is important to predict disease severity and eliminate other diseases as options?

Answer 18

Genetic testing

Question 19

What is the standard therapy for Hemophilia A?

Answer 19

Recombinant Factor VIII

Question 20

Why is Recombinant Factor VIII a better treatment option than plasma with the coagulation proteins in it?

Answer 20

Plasma is at a higher risk of containing an infection

Question 21

What is a possible MSK complication that can occur with Hemophilias?

Answer 21

Hemophilic Arthropathy

- Bleeds in the joints slowly creates arthritis

Question 22

The overall goal of treatment for Hemophilias is to?

Answer 22

Increase factor activity to limit bleeding

Question 23

Emicizumab is a very expensive treatment for Hemophilia. What does it do?

Answer 23

Binds to factor IXa and X

Question 24

Describe a mixing study

Answer 24

• Combine a patients plasma that has a prolonged PTT with a normal PTT
• Normal: Corrected PTT
• Abnormal: Failed to correct PTT
  == Inhibitor antibodies present if abnormal results

Question 25

In a mixing study using a factor deficient plasma, even ____ of normal factor levels will correct the PTT

Answer 25

50%

Question 26

In a mixing study that fails to correct, the patient's plasma contains?

Answer 26

Surplus of inhibitor antibodies

Question 27

What do inhibitor antibodies do?

Answer 27

Bind to coagulation factors and inactivate them which causes the persistent prolongation time (PTT)

Question 28

What can bind to coagulation factors and inactivate them to cause a prolonged PTT during a mixing study?

Answer 28

Inhibitor antibodies

Question 29

Patients that are (+) for Factor VIII inhibitors are said to have?

Answer 29

ACQUIRED Hemophilia A

Question 30

What is the treatment for acquired Hemophilia A?

Answer 30

Immunosuppression

Question 31

What are the demographics for those that get Acquired Hemophilia A?

Answer 31

- Usually older adults in post-partum | - Associated with autoimmune diseases

Question 32

Patients with congenital Hemophilia, can they produce antibodies to factors eventually?

Answer 32

Yes it is possible

Question 33

Deep Vein Thrombosis (DVT) is the same as?

Answer 33

(VTE) Venous Thromboembolism

Question 34

Virchow's Triad

Answer 34

- Increased risk for thrombosis 1. Endothelial Injury 2. Venous Stasis 3. Hypercoagulable

Question 35

Where do DVTs usually originate?

Answer 35

Lower extremity veins - Above knee = iliac or femoral - Below knee = NOT popliteal

Question 36

Symptoms of a DVT?

Answer 36

Unilateral pain, cramping sensation in the leg

Question 37

What can (PE) Pulmonary Embolisms cause?

Answer 37

Hypoxia and Right-sided Heart Failure

Question 38

What criteria can aid an index of suspicion for a VTE?

Answer 38

Wells, Geneva criteria

Question 39

What are common risk factors for VTE?

Answer 39

``` Prior DVT Surgery/hospitalization Immobilization Smoking Birth control Increasing age Malignancy ```

Question 40

If suspicions are towards the lower end for a DVT, what is a good lab test to do?

Answer 40

D-Dimer

Question 41

What is a D-dimer?

Answer 41

Degradation product of cross-linked fibrin

Question 42

If D-dimer is (-), what does that tell you?

Answer 42

There is NO thromboembolic event occurring

Question 43

NO thromboembolic event occurring D-dimer result?

Answer 43

(-)

Question 44

A compression ultrasound can diagnose?

Answer 44

DVT

Question 45

If a DVT is not present, what will the compression ultrasound show?

Answer 45

Compression of the venous lumen

Question 46

If a DVT IS present, what will the compression ultrasound show?

Answer 46

NO compression of the vein due to the clot

Question 47

A CT angiogram can diagnose?

Answer 47

PE

Question 48

If a PE is not present, what will the CT angiogram show?

Answer 48

White contrast in the vessels

Question 49

If a PE IS present, what will the CT angiogram show?

Answer 49

Not white contrast in the vessels

Question 50

Describe the ventilation/perfusion (V/Q) scan

Answer 50

- Inhale radiotracer dye - Inject radiotracer dye - Compare scans = SHOULD BE EQUAL

Question 51

If the V/Q scans show a mismatch, that could indicate?

Answer 51

PE

Question 52

Normally the ____ produces protein C and S

Answer 52

Liver

Question 53

Normally, what does Protein C and S do?

Answer 53

Block sites at VIII and X to STOP clotting cascade

Question 54

Normally, what does Protein C and S do?

Answer 54

Block sites at VIII and X to STOP clotting cascade

Question 55

Deficiency in Protein C and S will cause?

Answer 55

Thrombophilia - will not be able to stop clotting

Question 56

What is a paradoxical embolism?

Answer 56

Passage of an embolus from venous circulation into arterial circulation through a patent foramen ovale

Question 57

What anatomical abnormality is common in those under the age of 55 who experience a stroke?

Answer 57

Patent foramen ovale

Question 58

Diagnosis for a paradoxical embolism?

Answer 58

Transesophageal Echocardiography with bubble study (TEE)

Question 59

Passage of embolus from venous circulation into arterial circulation through a patent foramen ovale

Answer 59

Paradoxical Embolism

Question 60

Best treatment and how it works for thrombophilia?

Answer 60

Rivaroxaban and Apixaban | - (-) factor Xa

Question 61

ex. of drugs that inhibit factor Xa to treat thrombophilia?

Answer 61

Rivaroxaban and Apixaban

Question 62

What factors does Heparin inhibit?

Answer 62

2, 9, 10, 11

Question 63

What factors does Warfarin inhibit?

Answer 63

Vitamin K dependent factors 2, 7, 9 , 10

Question 64

What is a non-pharmacologic option to treat thrombophilia?

Answer 64

Inferior Vena Cava filter

Question 65

What is the duration of treatment for a provoked thromboembolism?

Answer 65

3-6 months