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xD3 Med Mgmt Ex2 > Hematology (Strauss) > Flashcards

Hematology (Strauss) Flashcards

1
Q

What are the 4 phases of blood clot formation?

A
  1. Vascular
  2. Platelet
  3. Coagulation
  4. Fibrinolytic
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2
Q

What is the phase of clot formation where blood vessels contract (collagen in the vessel contracts to stop the bleeding via a local myogenic spasm)?

A

Vascular phase

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3
Q

What is the phase of clot formation where platelets distort, clump, and stick to form initial platelet plug (will distort due to the action of instigators)?

A

Platelet phase

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4
Q

What is the phase of clot formation where blood profactors become factor and react to form fibrin (the basis for the clot)?

A

Coagulation phase

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5
Q

What is the basis for the blood clot?

A

Fibrin

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6
Q

What is the phase of clot formation where the clot dissolves to allow healing?

A

Fibrinolytic phase

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7
Q

What is the local autocoid that is released from traumatized tissue how long do they last, and where are they eliminated?

A

Synthesized in bone marrow by megakaryocytes
1-4 micrometers
7-10 day half-ife
Eliminated by macrophages in the spleen

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8
Q

Can platelets reproduce?

A

No. They have no nuclei.

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9
Q

Can platelets contract?

A

Yes. They have throbosethin, actin, and myosin, which are contractile proteins.

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10
Q

Why is a dental extraction the ultimate challenge to the patient’s ability to clot?

A

Can’t get primary closure.

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11
Q

Why are scaling and root planing potentially devastating if the patient can’t stop bleeding?

A

Can’t just easily stop the bleeding, plug it, close, etc.

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12
Q

The platelet surface is coated with what to keep them from adhering to normal endothelium but allows them to adhere to damaged cell walls?

A

Glycoprotein

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13
Q

Platelets have what on the membrane that activates multiple stages of the coagulation process?

A
  1. Phospholipids

2. Platelet Factor 3 (PF3)

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14
Q

Why is the half-life of a platelet and important consideration?

A

Factor in when taking patient off anticoagulation meds

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15
Q

What is released from platelets and endothelial cells to link the platelets with exposed collagen fibers?

A

Von Willibrand factor

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16
Q

How long until the initial platelet plug occur?

A

5-12 minutes

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17
Q

Is the platelet plug strong?

A

No, but it gives you initial stability

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18
Q

What can cause the fibrin clot to be formed?

A
  1. Damaged endothelium

2. Factors in the blood

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19
Q

How long does the fibrin clot take to form?

A

Up to 6-8 hours

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20
Q

How long with the fibrin clot (a scab) stay there?

A

A few days

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21
Q

Plasminogin becomes plasmin and dissolves what?

A

Fibrin clots. This is a process that is occurring all the time.

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22
Q

What is an irreversible platelet poison?

A

Aspirin

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23
Q

How long does the analgesia of aspirin last?

A

4 hours

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24
Q

For how long does aspirin irreversably poison your platelets?

A

7 days

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25
Q

What are necessary for platelet aggregation and activation of nearby platelets in order for the number of activated platelets to increase successively?

A
  1. ADP

2. Thromboxane A2

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26
Q

Initially, what activates platelets in the area of a wound?

A

Exposed collagen fibers in damaged vessel walls

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27
Q

What makes the platelet plug, which is loose at first, stronger?

A

Fibrin threads from coagulation phase interweaving through the platelet plug

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28
Q

What are 2 major parts of the coagulation system?

A
  1. Procoagulants

2. Anticoagulants

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29
Q

In normal blood flow, what part of the coagulation system predominates?

A

Anticoagulants

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30
Q

What are 2 things that start the coagulation process?

A

Material from damaged vessel walls in blood (things in blood that notice material or damage)

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31
Q

What are 2 ways to get to the formation of prothrombin activator complex in the coagulation cascade?

A
  1. Extrinsic pathway

2. Intrinsic pathway

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32
Q

What is the purpose of the prothrombin activator complex in the coagulation cascade?

A

Convert prothrombin (Factor II) to Thrombin (Factor IIa)

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33
Q

Which system includes XII, XI, IX, VIII?

A

Intrinsic system

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34
Q

Which system is mostly VII?

A

Extrinsic system

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35
Q

Which pathway includes X, V, IV, III?

A

The common pathway

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36
Q

What is the purpose of Thrombin in the coagulation cascade?

A

Converts fibrinogen (Factor I) to Fibrin (Factor IA)

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37
Q

What is the purpose of Fibrin (Factor Ia) in the coagulation cascade?

A

Form a meshwork around the platelet plug

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38
Q

The extrinsic and intrinsic pathways of coagulation meet where?

A

The common pathway

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39
Q

What factors are in the common pathway?

A

Factors 10, 3, 4, 5, 2, 1

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40
Q

What does the common pathway produce?

A

Factor 10 and Factor 5 and phospholipid form the prothrombin complex to convert prothrombin (Factor II) to Thrombin (Factor IIa) which converts Fibrinogen (Factor I) to Fibrin (Factor Ia)

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41
Q

What is the only factor in the extrinsic pathway for coagulation?

A

Factor 7

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42
Q

What stimulates factor VII of the extrinsic pathway?

A

Release of Factor 3 (Tissue thromboplastin) from traumatized tissue (Re: 3+7 = 10, 10 is the common pathway)

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43
Q

What are the factors in the intrinsic pathway?

A

12, 11, 9, 8

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44
Q

What stimulates the intrinsic pathway and what is the factor that starts off the intrinsic pathway?

A

Collagen from vessel wall and injured tissue activates factor 12

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45
Q

Collagen from the vessel wall and injured tissue not only activates Factor 12 of the intrinsic pathway, they also activate what?

A

Platelets. The platelets fwill produce PF3 which will come back into play at the end of the intrinsic pathway as Factor 9a interacts with Factor 8 and PF3 to stimulate Factor 10 of the common pathway

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46
Q

Factor 12 activated, becomes Factor 12a, and requires what two things to activate Factor 11?

A
  1. Kininogen

2. Prekallikrein

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47
Q

Once Factor 11 is activated by Factor 12a + kinenogen + prekallikrein, and becomes factor 11A, it activates what Factor next in the intrinsic pathway?

A

Factor 9

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48
Q

Factor 9 becomes Factor 9a after activation by Factor 11a, and Factor 9a activates what next and in what pathway?

A

Activates Factor 10 of the common pathway

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49
Q

What must factor 9a have help in order to activate Factor 10 of the common pathway?

A

Factor 8 and PF3

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50
Q

When Factor 10 is activated by Factor 9a + Factor 8 + PF3, what is created?

A

Factor 10 + Factor 5 + phospholipids form Prothrombin activator to activate Prothrombin (Factor II) to Thrombin (Factor IIa) which will activate Fibrinogen (Factor I) to Fibrin (Factor Ia)

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51
Q

Why do we want to know if a patient has liver disease?

A

Every proenzyme (except for Factor 8) are made in the liver. If the function of the liver is not good, you won’t have good clotting.

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52
Q

Why does cancer affect clotting?

A

Radiation therapy affects bone marrow, where the clotting happens

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53
Q

What is required for the Prothrombin activator (Factor 10 + Factor 5 + phospholipids) to convert Prothrombin (Factor 2) to Thrombin (Factor 2a)?

A

Calcium

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54
Q

Where is prothrombin (Factor 2) synthesized and on what vitamin does it depend?

A
  1. Liver

2. Vitamin K

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55
Q

What substance is Thrombin (Factor 2a)?

A

Proteolytic enzyme that acts on fibrinogen (Factor 1)

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56
Q

Fibrin (Factor IA) is syntehsized where and is it a monomer or a dimer?

A
  1. Liver

2. Monomer that polymerizes with other fibrin monomers to form fibrin fibers

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57
Q

As a dentist, can you order a CBC?

A

Yes

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58
Q

Are the initial bonds between fibrin (Factor Ia) monomers strong or weak?

A

Weak

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59
Q

What strengthens the bonds between fibrin monomers as they polymerize to make fibrin?

A

Fibrin stabilizing factor

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60
Q

Where is fibrin stabilizing factor released from?

A

Plasma globulin

Platelets

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61
Q

What is required toa ctivate fibrin stabilizing factor?

A

Thrombin (Factor 2)

62
Q

What does the clot contain once it is interwoven with the fibrin (Factor Ia) from the coagulation cascade?

A

Meshwork entraps blood cells, platelets, and plasma

63
Q

What occurs in the clot once the coagulation cascade has worked?

A

Platelets activate contractile proteins: thrombosthenin, actin, myosin. Causes stronge shrinkage and clot contraction.

64
Q

What is the purpose of the clot contraction?

A

The clot sealed the open vessel and the contraction brings the open edges together to increase hemostasis

65
Q

What causes clot fibrinolysis during the fibrinolytic phase?

A

Plasmin (a plasma protein)

66
Q

Plasmin is an activated form of what?

A

Plasminogen

67
Q

Where is plasminogen (inactive form of plasmin) intitially?

A

Entrapped within the clot

68
Q

How is plasminogen activated to Plasmin within the clot to begin fibrinolysis?

A

Converted via tissue plasminogen activator, t-PA

69
Q

What releases t-PA to activate plasminogen in the clot to plasmin to cause fibrinolysis?

A

Released slowly from injured vessel and tissue so it accumulates over a few days then activates plasminogen to plasmin

70
Q

What wil plasmin digest?

A
  1. Fibrin fibers
  2. Prothrombin (Factor 2)
  3. Factor 5
  4. Factor 8 (intrinsic)
  5. Factor 12 (intrinsic)
71
Q

Where is the plasmin also found beyond the clot?

A

Saliva

72
Q

Why is the plasmin in saliva a concern?

A

Patient with high salivary plasmin is at increased risk for alveolar osteitis (Dry socket) as the plasmin fibrinolysis the clot prematurely.

73
Q

How soon after a vascular injury that causes exposed subendothelium does vascular constriction occur?

A

Constriction is immediate

74
Q

How soon after a vascular injury that causes exposed subendothelium does platelet adhesion occur?

A

1-2 seconds

75
Q

How soon after a vascular injury that causes exposed subendothelium does platelet aggregation occur?

A

10-20 seconds

76
Q

How soon after a vascular injury that causes exposed subendothelium does the platelet plug form?

A

1-3 minutes

77
Q

How soon after a vascular injury that causes exposed subendothelium does consolidation of the platelet plug occur?

A

3-5 minutes

78
Q

How soon after a vascular injury that causes exposed subendothelium does fibrin stabilization of the plug occur?

A

5-10 min

79
Q

How soon after a vascular injury that causes exposed subendothelium does the coagulation cascade take to complete?

A

Hours

80
Q

How soon after a vascular injury that causes exposed subendothelium does clot breakdown occur?

A

Days

81
Q

How much blood loss should you expect in a hemophiliac during extraction and why?

A

Normal during extraction and immediately post-op because their platelets are fine

82
Q

When is the concern with clotting in a hemophiliac with respect to an extraction?

A

8 hours post op because their coagulation cascade is messed up

83
Q

What is the concern with hemostasis and cancer treatment, radiation therapy, and chemotherapy?

A

They affect the bone marrow where platelets are made

84
Q

What is the most common site for spontaneous bleeding?

A

Nose

85
Q

What is the normal range for platelet count?

A

145k to 350k

86
Q

What are 4 laboratory tests for hemostasis?

A

1, Platelet count

  1. Bleeding time (BT)
  2. Partial Thromboplastin Time (PTT)
  3. Prothrombin Time (PT)
87
Q

What is a lab test that reflects the patient’s ability to form and develop mature platelets. It is only a numerical count, and does not indicate the quality of the platelets

A

Platelet count

88
Q

What is an abnormal platelet count?

A

Below 100,000

89
Q

What platelet count requires platelets administered to the patient before an extraction?

A

Less than 50,000

90
Q

What platelet count has a risk for spontaneous intracranial hemorrhage (ICH)

A

Less than 20,000

91
Q

What lab test determines the quality of platelet function, i.e. platelets ability to form a plug after activation, done with a BP cuff at 40mmHg 6mm by 1mm incision on the forearm and blood absorbed by filter paper at 30 sec intervals until bleeding stops?

A

Bleeding time test

92
Q

What is the upper limit of normal bleeding time?

A

7.5 minutes

93
Q

Partial thromboplastin time (PTT) measure what 2 parts of the coagulation cascade?

A

Intrinsic and common

94
Q

Prothrombin time (PT) measures what part of the coagulation cascade?

A

Extrinsic and common

95
Q

Why does the partial thromboplastin time (PTT) only measure the intrinsic and common pathway?

A

Because factor 7 (extrinsic) and Factor 13 are not detected

96
Q

What is mixed with the plasma sample to get the PTT to measure the prothrombin time?

A

Phospholipid (phospholipid binds with Fact 10 and Factor 5 in the common pathway to get prothormbin activator complexa nd eventually fibrin. Intrinsic pathway must work (12 to 11 to 9 and 8 and PF3) to get a clot. The speed at which this occurs measures the ability of the intrinsic and the common pathways

97
Q

What is the normal range for a PTT (measure of the intrinsic and common pathways)?

A

28-34 seconds

98
Q

What patients would show a prolonged PTT?

A
  1. Von Willebrand’s disease (factor 8 intrinsic)
  2. DIC (Diffuse Intravascular Coagulation)
  3. Fibrinogen dysfunction (common pathway)
  4. Heparin Use (anticoagulant)
99
Q

Prothrombin time (PT) screens for abnormalities in what factors?

A

7 (extrinsic)
10 (common)
5 (common)
2 (common = Thrombin)

100
Q

What patients would a PT be used to screen?

A
  1. Warfarin patients
  2. Liver damage (where 7 and thrombin are made)
  3. Vitamin K deficiency (Vitamin K is required for Factor 2 Thrombin)
101
Q

What is a normal range for PT?

A

10-12 seconds

102
Q

Why use PTT to measure a Heparin patient and PT to measure a Warfarin patient when both patients are taking an anticoagulant?

A

Heparin inactivates thrombin (Factor II common path) and also Factors 9 (intrinsic), 10 (common), 11 (intrinsic), and 12 (intrinsic) and prevents conversion of fibrinogen to fibrin (common). Only acting on the common pathway, so must test with PTT. Warfarin/Coumadin depletes Vitamin K which reduces synthesis of clotting factors in the liver that require Vitamin K (2 (common) 7(extrinsic), 9(intrinsic), and 10 (common)). Therefore, the extrinsic and common path is indicated as 7 is affected and the only test that reads Factor 7 is PT.

103
Q

What is the international normalized ratio (INR)?

A

INR = (patient’s protime / mean of normal range)

104
Q

What surgical therapy can be done on a patient with INR less than 3.5?

A

Single extraction with local measure (pack with gel foam, suture, maybe topical thrombin)

105
Q

If the patient has thrombocytopenia, marrow disease, or on a chemotherapeutic drug, what lab test should be ordered before performing surgery?

A

Platelet count (norm 145k to 350k)

106
Q

If a patient is taking aspirin (ASA, COX-1 inhibitors (aspirin does this) or other drugs that inhibit platelet aggregation, what lab test should be ordered before performing surgery?

A

Bleeding time (high end is 7.5 min)

107
Q

If a patient is taking Coumadin or Warfarin, has liver disease (think Vitamin K problem and factor synthesis problem) or has a vitamin malabsorption problem, what lab test should be ordered before performing surgery?

A

PT/INR (PT norm is 10-12 seconds, desired INR is ????????)

108
Q

If a patient was given Heparin IV in the hospital or takes Pradaxa, or has Von Willebrand’s disease, what lab test should be ordered before performign surgery?

A

PTT (norm 28-34 seconds)

109
Q

What are 3 classifications of bleeding disorders?

A
  1. Disorders of coagulation
  2. Non-thrombocytopenic purpura
  3. Thrombocytopenic purpura
110
Q

What are 2 inherited disorders of coagulation?

A
  1. Hemophilia A (X-linked (males), Factor 8 deficiency)
  2. Hemophilia B (Christmas disease, Factor 9 deficiency)
    NOTE: Both are intrinsic pathway problems, test with PTT
111
Q

What are 6 examples of acquired disorders of coagulation?

A
  1. Liver disease
  2. Vitamin K deficiency
  3. Anticoagulant therapy
  4. DIC
  5. Primary fibrogenolysis
  6. Marrow disease
112
Q

How much of liver must be gone before the patient has bleeding problems?

A

70%

113
Q

What are the Vitamin K dependent clotting factors?

A 
Factor 2 (common)
Factor 7 (extrinsic)
Factor 9 (extrinsic)
Factor 10 (common)
114
Q

What is a DIC (disseminated intravascular coagulopathy)?

A

All clotting factors get used up and patient bleeds out. This is a risk following labor.

115
Q

When is the danger with coagulation for a Hemophilia patient?

A

Hours after an extraction. They formed a platelet plug but lack factor 8 (Hemophilia A) or factor 9 (Hemophilia B) meaning the platelet plug will not be stabilized by fibrin and the patient will start to bleed again

116
Q

Which hemophilia is more common?

A 
Hemophilia A (factor 8 deficiency) 1:5k to 10k
Hemophilia B (factor 9 deficiency) 1:2.5k to 30K
117
Q

Non-thrombocytopenic purpura bleeding disorders have to do with what?

A

Abnormal vascular wall integrity which prevents normal contraction at injury or a platelet aggregation problem

118
Q

What are examples of things that can lead to non-thrombocytopenic purpuras?

A
  1. Connective tissue vascular disease (Systemic Lupus Erythemous, Scleroderma)
  2. Vitamin C deficiency (Scurvy)
119
Q

What is the most common non-thrombocytopenic purpura that are caused by platelet function problems?

A

Von Willebrand’s Disease

120
Q

What ist he most common inherited bleeding disorder?

A

Von Willebrand Disase

121
Q

What is Von Willebrand factor?

A

A bridge that binds platelets and endothelial cells

A carrier protein for Factor 8 (intrinsic path)

122
Q

A person with Von Willebrand’s disease will have what type of PTT?

A

Abnormal PTT (due to factor 8 problem) increased bleeding time (because platelet aggregation is messed up)

123
Q

How can von Willebrand disease be treated?

A
  1. Factor 8 replacement
  2. Desmopressin (increases VWF, Factor 8 and t-PA, shortening PTT and bleeding time)
  3. Antifibrinolytics
  4. Topical thrombin
124
Q

All of the clotting factors are made in the liver except for what?

A

Factor 8

125
Q

What is Dr Strauss’s rule for herbal supplements?

A

Anything starting with a G causes bleeding: Gingko bilboa, Garlic, Saw Palmetto (?)

126
Q

For a patient with a marrow disease resulting in thrombcytopenia, what is the desired platelet count for low bleeding risk procedure?

A

50-70K platelets

127
Q

For a patient with a marrow disease resulting in thrombocytopenia, what is the desired platelet count for high bleeding risk procedure?

A

80K platelets

128
Q

An apheresis unit (6 pack) is expected to raise the platelet by how much in how long?

A

30K platelets w/in 10 minutes to 1 hour

129
Q

Anything that poisons a platelet lasts for how long?

A

Platelet lifetime = 7 days

130
Q

Heparin is used on what patient type and how will this affect treatment scheduling?

A

Patient on renal dialysis. Perform procedures on non-dialysis days

131
Q

What is a concern if patient is on long-term antibiotic therapy?

A

Vitamin deficiency leading to a non-thrombocytopenic purpura caused by lack of Vitamin K uptake in gut

132
Q

Which is shorter-acting: coumadin or heparin?

A

Heparin

133
Q

How long after stopping coumadin should it take to get a normal PT?

A

2-3 days

134
Q

Is stopping anti-platelet therapy (Aspirin or Plavix) necessary prior to surgical procedure and what must the patient be told?

A

No. Inform the patient that they will bleed longer.

135
Q

A patient that has one of the following: prosthetic valve, atrial fibrillation, DVT, stroke risk, or hypercoagulable state would be given what drug and what test would we use to determin their coagulation ability?

A

Coumadin

PT

136
Q

What patient types are at a high risk when taken off of Coumadin?

A 
Mitral Valve patient
A-Fib patient more than 75 years old
Diabetics
DVT early in the diagnosis (less than 2 months)
Hypercoagulable
137
Q

If a patient is on Pradaxa and has more than 50ml/min of creatine clearance, how long must they be off the Pradaxa before dental treatment?

A

1-2 Days, then restart once hemostasis is achieved

138
Q

What is Lovenox?

A

Low molecular weight Heparin used to bridge patient perioperatively from other anticoagulants. Stopped 24 hours prior to procedure to allow 5 half-life eliminations (half-life is 4-6 hours)

139
Q

When patient is bleeding, what is most important?

A

Find out why bleeding (local or systemic)

140
Q

What is a characteristic of oral bleeding with a systemic cause?

A

Will be generalized and out of magnitude to injury

141
Q

If bleeding is immediate what is the cause?

A

Physical

142
Q

Early bleeding after treatment is what cause?

A

Platelet problem

Loss of clot

143
Q

Delayed bleeding after treatment is what cause?

A

Coagulation problem

Loss of clot

144
Q

What is an immediate treatment for bleeding?

A

Pressure

145
Q

What are other methods to stop bleeding beyond pressure?

A
  1. Gel foam scaffold
  2. Topical thrombin to catalyze fibrin
  3. Amicar to inhibit plasmin and maintain clot
  4. Cautery/siler nitrate to coagulate cellular proteins
  5. DDAVP (Desmopressin) to increase VWF and contraction of vasculature
  6. Blood products
146
Q

What is a homeopathic method for pressure to stop bleeding?

A

Bite on teabag, which release tannic acid

147
Q

What is the problem with giving epinephrine for hemostasis?

A

False sense of hemostasis

148
Q

What is indicated for injection hematoma from doing PSA?

A

Long-term pressure, antibiotics, follow for infection or trismus

149
Q

Hypercoagulability is most commonly caused by what?

A

Factor 5 Leiden mutation

150
Q

A patient taking Aspirin for heart disease prevention that has early bleeding with EXT, bleeding is caused by what?

A

Imparied platelet aggregation

xD3 Med Mgmt Ex2 (6 decks)

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