Principles Flashcards

1
Q

What components interact in haemostasis?

A
platelets
coagulation factors 
coagulation inhibitors
fibrinolytic processes
blood vessels/endothelium/cell membranes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the steps haemostasis + what is their timefram

A

Seconds -> minutes (immediate)
= Primary haemostasis
- get platelet plug

Minutes
= Secondary haemostasis
- fibrin network secures clot in place

Mins -> Hrs
Fibrinolysis
- lysis of clot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What occurs in primary haemostasis?

A
  • damaged vessel wall -exposes collagen
    => platelets are activated when bind collagen

platelets release ADP and 5-HT (serotonin)

5-HT = serotonin (5-HT) - powerful vasoconstrictor

ADP - causes other platelets to activate and change shape
- platelet adhesion + aggregation -> plug

platelets also synthesise other mediators - eg thromboxane from arachadonic acid => stimulate further activation of platelets

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

via what mechanism do platelets aggregate and adhere

A

fibrinogen bridging between GPIIb/IIIa receptors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What happens in secondary haemostasis?

A
  • activation of coagulation factors

- formation of fibrin -> fibrin network => secure clot into place

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What happens in fibrinolysis

A

lysis of clot -> back to smooth surface on endothelium wall

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the components of Virchow’s triad

A

Vessel wall
Blood composition
Blood flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Virchow’s triangle - vessel wall - describe

what effects can it have on haemostasis

A

endothelial surface of vessel wall is dynamic + active - interacts with blood/subcutaneous tissue

can be anti or pro-thrombolytic (depending on expression of surface proteins/secreted proteins)

the lining differs with location and age

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Which components of Virchow’s triad can we test to look at clotting/bleeding disorders

A

Blood composition (cells, plasma)

Blood flow (cardio factors, function)

Can’t test vessel wall integrity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Virchow’s triad - blood composition; what components are important

A

Blood cells

  • RBC
  • WBC
  • platelets

Plastma - coagulation/clotting system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the 2 key components of the coagulation system?

A

tissue factor - is released by vessel wall, kicks things off

thrombin - key enzyme that must be controlled
- converts fibrinogen -> fibrin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the phases of the coagulation model? What are the steps within each phase

A

(1) Initiation phase
- vessel wall injury - contact between subendothelial cells + blood
- tissue factor is exposed
- tissue factor binds FVIIa - and this activates FIX + FX
- FXa then binds Fva on cell surface

(2) Amplification phase
- the FXa/FVa complex converts a small amount of prothrombin -> thrombin

thrombin activates FVIII, FV, FXI and platelets

then FXIa converts FIX to FIXa

the activated platelets bind FVa, FVIIIa, FIXa

(3) propagation phase = thrombin burst

FVIIIa/FIXa comple activates FX on activated platelet surface

FXa + FVa convert a large amount of prothrombin -> thrombin

=> this leads to the formation of a stable fibrin clot

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

why is thrombin esential for clot formation?

A

converts fibrinogen -> fibrin

  • clot formation
  • reinforcement of platelet plut
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what happens if there is too much thrombin?

or too little?

A

too much = thrombosis

too little = bleeding

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

how does inactivation of thrombin occur

A

Thrombin inactivation:

(1) negative feedback
= thrombin binds thrombomodulin -> activates protein C
- APC inhibits VIIIa and Va
- APC also inactivates the inhibitor of tissue plasminogen (allowing fibrinolysis)

(2) Other mechanisms
a. enzyme inhibitors
= antithrombin - binding induces irreversible inhibition (accelerated 1000fold by heparin)
b. binding to heparin co-factor II, dermatan sulphate, a-2 macroglobulin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

how does heparin work

A

accelerates antithrombin-thrombin binding (irreversible inhibition of thrombin)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what is a fault of haemostatic testing?

A

isn’t a true measure of physiology - usually we are testing one part of the system in isolation

  • however it can hopefully predict clinical ehaviour
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what kinds of tests can we use to test haemostasis?

A

can’t test blood vessel wall

can test platelets - number, function, appearance

we have a range of tests for the coagulation system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

what are some tests of the coagulation system

A

tests of risk of bleeding
- APTT, INR etc

we can do specific assays on clotting factors, fibrinogen, specific assays

and we can genotype for disorders of clotting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are some examples of global functional assays for haemostasis?

A

PT = prothrombin time - initiate clotting (calcium, heating) + measure time to make a clot

INR = standardisation of PT

APTT - activated partial thromboplastin time - similar to PT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Why is INR used?

A

Different labs will have different results for prothrombin time (PT) due to use of different reagents

INR gives a way to standardise these results = international normalised ration

INR = (patient PT/mean normal PT)^ISI

where ISI = sensitivity index

INR is used to monitor warfarin use

22
Q

what can APTT tell you about?

A

factor deficiencies (XII, XI, IX, X)
lupus anticoagulant
heparin monitoring

23
Q

Haemostatic disorders what are type I and type II

A

Type I - low amount and function

Type II - normal amount, but non-functioning

24
Q

How does fibrinolysis occur

A

plasmin - dissolves fibrin

25
What are the 2 pathways to the activation of thrombin from prothrombin
(1) extrinsic (to blood) = in vivo: damaged tissues release thromboplastin - stimulates (2) intrinsic (to blood - will clot in tube) = in vitro: exposed collagen or other material, negative charges (eg glass)
26
why is coagulation a cascade?
each step is a protease -> catalyses another step, and this amplifies small signal -> large amount of product
27
which pathway is faster to coagulation - extrinsic/intrinsic?
extrinsic
28
What are some vessel wall factors that can lead to improper haemostasis
vessel damage -> thrombus formation eg - atherosclerosis
29
what happens to haemostasis if blood composition changes
can have hypercoagulability
30
what happens to haemostasis if blood flow stops (blood stasis)
thrombus formation eg. AF, DVT
31
Common causes of anaemia
- iron deficiency (blood loss) - iron/vitamin deficiency - chronic disease - aplastic - infection/drugs/autoimmune - bone marrow disease - haemolytic - sickle cell
32
acute blood loss - what sort of anaemia will you see
normochromic | normocytic
33
iron deficiency/blood loss - what sort of anaemia will you see how might it present clinically
microcytic, hypochromic anaemia (can't produce Hb properly) might present as pica!
34
folate or B12 deficiency - what sort of anaemia will you see
macrocytic | reticulocytopaenia
35
anaemia of chronic disease - waht will the RBC look like +pathophysiology which chronic diseases
chronic inflammation -> inflammatory mediators (IL6) increase hepatic hepcidin hepcidin = inhibit iron absorption in gut ones with chronic inflammation (chronic microbial, chronic immune - RA etc; neoplasms)
36
What is anaemia? How do we measure it
Anaemia = reduction of total circulating red cell mass below normal limits Measured by ↓haematocrit ↓[Hb]
37
What are the classifications of anaemia according to RBC morphology?
Size - normocytic/microcytic/macrocytic Degree of haemoglobinisation (colour) - normochromic, hypochromic Shape
38
In general, what causes microcytic, hypochromic anaemias?
Disorder of Hb synthesis (eg iron deficiency)
39
In general, what causes macroscopic anaemias?
Impairment of maturation of erythroid precursors
40
What changes can occur in kidney/liver/myocardium due to anaemia
hypoxia -> fatty change in myocardium: if severe enough - can get cardiac failure (and this compounds the hypoxia) Myocardial hypoxia may manifest as angina If there is acute blood loss + shock -> can get oliguria + anuria (renal hypoperfusion)
41
What are the characteristic morphological changes of megaloblastic anaemias?
abnormally large erythroid precursors + RBC
42
Why is there pancytopaenia in megaloblastic anaemia?
Derangement of DNA synthesis causes most precursors to undergo apoptosis in marrow
43
What is pernicious anaemia?
specific form of megaloblastic anaemia caused by autoimmune gastritis -> this impairs production of intrinsic factor -> B12 deficiency
44
Who is at risk of folate deficiency?
need grossly deficient diets - very old, chronic alcoholics, indigent or those that have increased requirement (pregnancy, infancy, haemolytic anaemias, disseminated cancer)
45
causes of iron deficiency anaemia
diet impaired absorption increased requirement chronic blood loss
46
What is aplastic anaemia? Causes what is the RBC morphology
Chronic primary haematopoietic failure + attendant pancytopenia Causes - many are autoimmune, otherwise drugs, chemicals (eg chemo, benzene), EBV, VZV etc these cause marrow suppression RBC morphology (in this + other marrow failures) - low count, but appear normal
47
What is the erythropoiesis pathway? Which factors are required for each step?
Multipotent HSC ↓ (Flt3L, Tal1/SCL) myeloid SC ↓ (EPO - erythropoietin) erythroprogenitor ↓ EPO pro-erythroblast ↓ basophilic erythroblast ↓ polyprochromatophilic erythroblast ↓ orthocytochromatic erythroblast (normoblast) – has nucleus and organelles ↓ Fe is important for late erythroblasts – needed for reticulocyte production [IN BLOOD] reticulocyte – still some organelles ↓ enucleation RBC ↓ 120 days dies
48
What factors determine erythrocyte size?
(1) appropriate signalling in erythropoiesis pathway (2) time of maturation (3) proteins (4) Hb formation (5) genetic abnormalities (eg thalassaemia) thalassaemia → autosomal recessive → make strange shaped RBCs`
49
what determines concentration of Hb (3)
Iron levels transferrins (carry around iron) ferritin (intracellular storage)
50
Where are the following stored: Iron B12 Folate
Iron - liver - bound to ferritin - Hb - myoglobinn - bound to transferrin in blood B12 - liver Folate - nowhere