Hemodynamics III & IV Flashcards by tcarlso 3

What are the factors that coumadin affects?

8, 9, 10, 2 (1972), protein C and protein S

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What is INR?

PT pt / PT nl

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What pathway does PT measure?

Extrinsic pathway

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What pathway for PTT measure?

Intrinsic pathway

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What is the normal range of INR?

0.8-1.2

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What drugs prolongs the intrinsic pathway (and thus PTT)?

heparin, hemophilia, and antiphospholipid antibody

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How do you distinguish if someone have a factor deficiency vs an inhibitor?

Mix patient’s sample with normal plasma. If clots, then patient has it. If no clot, then there is an inhibitor

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What are the two factors not measured by PT or PTT?

7 and 13

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Low dose heparin has what effect on PT/PTT?

PT = nl
PTT = prolonged

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High dose heparin has what effect on PT/PTT?

PT = Prolonged
PTT = Prolonged

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Low dose warfarin has what effect on PT/PTT?

PT = Prolonged
PTT = Normal

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HIgh dose warfarin has what effect on PT/PTT?

PT = Prolonged
PTT = Prolonged

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What happens to the sensitivity of pts to warfarin with age?

Increase sensitivity

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What are the contraindications to Warfarin?

Pregnancy
If hemorrhage is a risk
EtOH abuse
Dementia

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What are the signs of warfarin overdose?

Hematochezia
Bruising
Epistaxis
Persistent bleeding

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What is Warfarin necrosis?

Warfarin causes low levels of protein C, causing excessive clotting (hypercoagulable state)

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What strategy do we take to prevent Warfarin necrosis?

Give heparin first with Warfarin’s first dose

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What is heparin-induced thrombocytopenia?

Antibodies form against platelet factor 4 (which normally blocks heparin)

This induces a prothrombotic state

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What is HIITS?

Heparin-induces thrombocytopenia with thrombosis syndrome

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What is Bernard-Soulier disease?

AR disease where there is a defect of platelet adhesion d/t defect in Glycoprotein Ib

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What is Glanzmann Thrombasthenia?

Defect of platelet aggregation d/t a defect in glycoprotein IIb/IIIa.(Recall this links platelets together)

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What is thrombotic thrombocytopenic purpura (TTP)?

Antibodies directed against von Willebrand factor cleaving protease, ADAMTS-13,(this normally breaks up von Willebrand factor)

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Are PT/PTT affected in Bernard-Soulier or Glanzmann disease?

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What is idiopathic thrombocytopenia purpura (ITP)? What is the treatment for recurrent?

Antibodies directly against platelets, leading to spleen destruction, resulting in thrombocytopenia

Treatment = splenectomy

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What is aplastic anemia?

Pancytopenia, marrow's is fibrosed, no more blood cells

What is von Willebrand's disease?

Deficiency of von Willebrands antigen, causing coagulopathies

What are the clinical symptoms of von Willebrand disease?

Easily bruised Epistaxis Gingival bleeding Menorrhagia

What is hemophilia A the result of? How is this passed on?

Factor 8 deficiency | XR

What is hemophilia B the result of?

Factor 9 deficiency | XR

What is hemophilia C the result of? How is this passed on?

Factor 11 deficiency | AR

How do you treat hemophiliacs?

Recombinant factor, or plasma

What are the major complications with hemophilia?

Deep, internal bleeding | Joint damage

What are the problems with transfusions for hemophiliacs?

Risk for infx | Adverse immune rxn

Deficiencies with which factors are particularly problematic?

5, 7, 8, 9, 11

How do we monitor factor deficiencies?

PTT/PT

What are the factor deficiencies that are usually not clinically significant?

Factor 12

How do platelet deficiencies appear clinically?

Purpura, petechiae, or ecchymosis

What is DIC? What does this lead to?

Systemic problem of coagulation where tiny fibrin thrombi form throughout the body. Leads to thrombocytopenia

What is meant by the term consumptive coagulopathy?

All of the platelets are used up

What causes DIC? What two things does this cause?

Activation of thrombin systemically, causing fibrin formation and consumption of platelets

Why does DIC result in organ failure?

Clots form in organs, leading to cut off blood supply

Why does DIC result in bleeding?

All the platelets are used up

What are schistocytes? What causes these?

Sheared RBCs, caused by strands of fibrin in capillaries cutting them. (this is seen in DIC)

What does a D-dimer measure?

Measures plasma cleaved insoluble cross-linked fibrin

What is the treatment for DIC?

Treat underlying cause | Use blood products

What are the components of Virchow's triad?

Hypercoagulable state Endothelial injury Circulatory stasis

What is the dominant influence on thrombosis?

Endothelial injury

What happens to fibrinogen to fibrin conversion during thrombus formation?

Increased markedly

What causes endothelial injury?

LDL cholesterol buildup Smoking HTN DM

What is the most common hypercoagulable state?

Factor 5 leiden

What does prothrombin mutations lead to?

Hypercoagulable state

What are the rare deficiencies that result in a hypercoagulable state?

Antithrombin III Protein C Protein S

What are pts with Factor 5 leiden susceptible to?

DVTs

What is the problems with factor V leiden?

Resistance of factor V to Protein C

What is the amino acid change involved with factor V leiden?

Q substitutes for R at 506 position

What is the primary risk for thrombosis?

Bedrest or long periods of immobility

What are the two heart problems that pose a risk for thrombosis?

A fib and MI

What is antiphospholipid antibody syndrome?

Serum antibody against anionic phospholipids, causing a hypercoagulable state

What pts have antiphospholipid antibody syndrome?

SLE pts

What is turbulence?

Disruption of the normal, laminar flow of blood

Why is blood turbulence problematic?

Forms countercurrents of blood, causing local pockets of stasis, and prevents dilution of clotting factors

What can cause turbulence?

Ulcerated atherosclerotic plaques MI Afib

What is hyperviscosity syndrome?

Polycythemia

What does turbulent flow cause to endothelial cells to secrete (3)?

Secreted angiotensin II Endothelin 1 PDGF

What does turbulent flow cause to the amount of migration of immune cells?

Increases

venous thrombi usually occur as a consequence of what?

Stasis

Arterial thrombi occur where?

At sites of endothelial injury

What are the two major problems with arterial thrombosis?

Occlusion | Emboli

Where do clots form that cause strokes?

Carotid bifurcation

What are arterial thrombi composed of?

Platelets Fibrin RBCs Leukocytes

What is gruel?

The foam cells in the endothelium

Stenting is indicated for AAA when they are how big?

5 cm or greater

What are lines of Zahn?

Lines in a thrombus, indicating alternating layering of platelets, fibrin, and erythrocytes

What cells do venous thrombi contain more of?

Erythrocytes

Where do venous thrombi usually occur?

Deep veins in the leg

Where is the turbulence found in veins?

Behind the valves

What is a phlebothrombosis?

Venous thrombosis

What are the problems with superficial thrombi in the legs?

Varicose veins--NOT PEs

What percent of pts with DVTs have symptoms in their leg?

50%

What are the risk factors for venous thrombosis?

CHF Trauma Surgery Pregnancy

What is trousseau syndrome?

Thrombi form in larger veins in different parts of the body d/t S proteases released by tumors, that activates factor 10. Also membrane vesicles released that are prothrombotic

What are the five fates of a thrombus?

``` Emboli Resolution Propagate Recanalized Incorporated into the wall ```

What do emboli usually occur from?

Dislodged thrombus

What are the common causes of arterial emboli?

A fib Mitral stenosis Endocarditis

What is the most common type of thrombus?

Intracardiac mural thrombi

Where do arterial emboli usually go?

``` Lower extremities (75%) Brain (10%) ```

What are paradoxical emboli?

Rare condition in which an embolus originating from the venous circulation passes through an interatrial or interventricular defect to gain access to the systemic circulation

What percent of PEs are caused by DVTs?

95%

What is a saddle embolus?

Lodge across the pulmonary vessel bifurcation

Where do medium emboli usually end up?

Medium sized branches

Where do small emboli end up?

Peripheral vessels, usually silent

What do recurrent emboli cause?

Cor pulmonale

Wedge like infarcts are caused by what sized emboli?

Medium

What is a V/Q mismatch?

Different between ventilation and circulation

What are fat emboli? What do they usually come from?

Fat, usually from fractures of large bones or burns

What do fat emboli look like microscopically?

Clear vacuoles w/in the vessels

True or false: fat emboli usually have no effect

True (90% no effect)

What is the stain used to identify fat emboli?

Oil red O stain

What are the symptoms of a fat emboli? (3)

Tachypnea/dyspnea Diffuse petechial rash CNS symptoms if fat there

What are air embolisms caused by?

Obstetric procedures | Vascular procedures

How much air is needed to cause air embolisms?

>100 cc

What is decompression sickness?

Sudden changes in atmospheric pressure causes N gas embolize

What is the bends?

Decompression sickness in skeletal muscles and around joints

What are the chokes?

Gas emboli in the lungs d/t decompression

What is the treatment for decompression sickness?

Slow decrompression

What is an amniotic fluid embolism?

If amniotic fluid gets into the maternal blood, causes severe clots

What does amniotic fluid emboli consist of?

Epithelial cells from fetus | Lanugo hair

What are four causes the infarction, besides thrombus?

Vasospasm (cocaine) Hemorrhage Compression of vessel Twisting of vessel

venous causes of infarct are more likely in organs with what?

Single venous outflow

Venous thrombosis usually induces only congestion, not infarction. Why?

Usually have more than one venous outflow

What is the most critical factor in determining if an infarct will develop?

Anastomoses

Why are the spleen and kidney particularly susceptible to infarction?

End arterial system

What is a red infarct? Shape?

Infarct with a hemorrhage in them Usually wedge shaped

What causes a red infarct?

venous occlusions Loose tissues Tissues with dual circulation

What causes a white infarct?

Type of arterial occlusions in solid organs with limitations of blood flow into areas of ischemic necrosis

What is a septic infarct?

Infarct where the origin of the embolus is an infected tissue

What is the major source of septic infarcts?

Vegetations from bacteria on heart valves