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Prolonged bleeding Flashcards

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1
Q

What are congenital causes of prolonged bleeding?

A

Haemophilia A and B
Von Willebrand’s Disease

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2
Q

How does renal failure impact bleeding?

A

Impairs platelet function

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3
Q

What are acquired causes of prolonged bleeding?

A
  • Therapeutic use of:
    Anticoagulants
    Antiplatelets
  • Renal failure
  • Hepatic failure
  • Bone marrow failure
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4
Q

What is purpose of haemostasis?

A

Prevent blood loss

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5
Q

When does haemostasis start?

A

When BV damaged / severed / ruptured

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6
Q

What are the mechanisms of haemostasis?

A

Vascular spasm
Platelet activation
Platelet aggregation
Activation of factor X and prothrombin
Fibrin mesh
Blood coagulation

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7
Q

How does hepatic failure impact bleeding?

A

Liver = source of clotting factors
Can impair absorption of vit K to synthesise factors 2, 7, 9, 10

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8
Q

How does bone marrow failure impact bleeding?

A

Reduce production of functional platelets

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9
Q

What can lead to bone marrow failure?

A

Leukaemia
Therapeutic drugs
Renal failure
Alcohol abuse

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10
Q

How does Warfarin work?

A

Interferes with vit K metabolism
Preventing synthesis of factors 2,7, 9, 10
Affects both intrinsic and extrinsic pathways

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11
Q

Importance of factor X?

A

Gets converted to factor Xa which converts prothrombin to thrombin which converts fibrinogen to fibrin which forms the clot

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12
Q

How do DOACs work?

A

Affects factor X conversion into factor Xa

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13
Q

What type of drug is Warfarin?

A

Vitamin K antagonist
Type of anticoagulant

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14
Q

Examples of DOACs?

A

Apixaban
Rivaroxaban
Edoxaban
Dabigatran

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15
Q

Disadvantages of warfarin over DOACs?

A
  • Affected by foods
  • Takes a long time to work
  • Long time for effects to wear off after meds stopped
  • Affects both intrinsic and extrinsic pathways, not specific, less predictable
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16
Q

Which foods can interact with Warfarin?

A

Green tea
Liver
Broccoli
Sprouts
Grapefruit
Alcohol
Pomegranate / cranberry juice

Items rich in Vitamin K

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17
Q

Which drugs interact with Warfarin and increase INR?

A

Miconazole
Fluconazole
Metronidazole
Erythromycin

All increase risk of haemorrhage

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18
Q

What prevents activation of platelets and clotting factors in BV normally?

A

Endothelial cells lining BV wall

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19
Q

What happens when BV wall damaged?

A

Lining of endothelial cells gone
Collagen fibres exposed
Foreign material introduced into BV
Platelets activated
Intrinsic and extrinsic mechanisms activated

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20
Q

How is blood clotting balanced?

A

Thrombin simultaneously catalyses plasminogen conversion to plasmin
Plasmin breaks down fibrin clots
Process fibrinolysis

21
Q

Warfarin pt needs XLA what to do?

A

Never stop medx
Evidence base says stopping Warfarin cause more problems and SDCEP guidance
Check INR yellow book
If stable get INR within 72 hours of XLA
If unstable get INR within 24 hours of XLA
INR 4 or below
Proceed with XLA
Local haemostatic measures

22
Q

What is most prolonged bleeding caused by in practice?

A

Iatrogenic
AKA Prescribed medx
E.g. oral antiplatelets, anticoagulants

23
Q

Examples of oral anti platelets

A

Aspirin
Clopidogrel
Dipyramidole
Ticlopidine

24
Q

How do anti platelets work?

A

Aspirin irreversibly binds to platelets, prevents aggregation
Clopidogrel irreversibly binds to receptors, prevents aggregation
Ibuprofen reversibly binds to platelets

25
Q

How often are platelets renewed?

A

10 days

26
Q

Which pts likely to take aspirin / clopidogrel?

A

Stroke
Vascular disease
Ischaemic heart disease
Thromboembolic disease

27
Q

How to manage aspirin pt?

A

Do not stop aspirin
Takes 10 days for platelets to renew
Weeks for effects to be reversed
Risk of stopping greater than risk of continuing
Use local haemostatic measures

28
Q

What is thrombocytopenia?

A

Reduced platelet count

29
Q

What is normal platelet count?

A

150 000 - 450 000 / microlitre

30
Q

What can cause thrombocytopenia?

A

Leukaemia
Anaemia
Pregnancy
Chronic alcohol abuse
Medx
Hereditary

31
Q

How to manage pt with thrombocytopenia?

A

Safe to treat platelet count < 80 000
Get advice haematologist
May require steroids / platelet transfusion

Bruise very easily = ecchymosis

32
Q

What types of pt on Warfarin?

A

Atrial fibrillation
Recurrent DVT or prev pulmonary embolism
Prosthetic heart valve

33
Q

How is haemostasis measured?

A

Prothrombin time

34
Q

What does prothrombin time reflect?

A

Activity of factor 7 in clotting cascade

35
Q

How is PT used?

A

Calculate INR

36
Q

What is INR?

A

International Normalised Ratio

= PT of pt / Mean PT of healthy group

37
Q

What is INR in health compared to therapeutic warfarin range?

A

Health = 1
Warfarin = 2 - 4

38
Q

What should anticoagulation record contain?

A

Yellow book
Reason for anticoagulation
Target INR
Contact details of clinic
Warfarin dosages
Recent INR records - stable or unstable?

39
Q

What is half life of Warfarin? What does this mean?

A

48 hours
Takes 2 days for changes in dose to affect INR

40
Q

Management of Warfarin pt using anti fungal for angular chelitis?

A

Antifungals = metronidazole / fluconazole / miconazole
Antifungals contraindicated for Warfarin pts as increase INR
Do not stop Warfarin
Prescribe another anti fungal agent

41
Q

Risks associated with increased INR <4?

A
  • Increase risk of haemorrhage
  • Retinal haemorrhage = visual loss
  • Haemoarthrosis = loss knee function
  • Subdural haematoma = death
42
Q

Which drugs interact with Warfarin to decrease INR?

A

Carbamazepine
Increases risk of thrombosis

43
Q

What drug can reduce prolonged bleeding?

A

Tranexamic acid

44
Q

How does tranexamic acid work and when used?

A

Stops plasminogen being converted to plasmin
So no fibrinolysis
Stops clots being digested
Not commonly used
Mouthwash

45
Q

Why do not prescribe aspirin to children U16

A

Reyes syndrome

46
Q

Which aspect of haemostasis do antiplatelets affect?

A

Platelet aggregation

47
Q

Which aspect of haemostasis does Warfarin affect?

A

Clotting cascade
Factors 2, 7, 9, 10

48
Q

Virchow’s Triad?

A
  1. Damage to endothelial lining
  2. Hyper coagulable state
  3. Arterial / venous blood stasis

Predispose to thrombosis

CMS (10 decks)

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