Describe Virchow's Triad
Thrombosis is due to stasis, vessel wall injury, hypercoag in isolation or in combination with eachother
predisposing factors for VTE
- -co-morbidities: Ca, COPD, HITT, IBD, others
- -Rx: the pill, HRT, tamoxifen, thalidomide
Two types of acquired thrombophilia
- anticardiolipin (ACL) Ab
- Lupus anticoagulant Ab (LUPAC)
4 symptoms and 4 signs of acute PE
symptoms: dyspnea, pleuritic chest pain, cough, hemoptysis
Sign: tachypnea, rales, tachycardia, 4th heart sound
Short term management of VTE
- -IV heparin
- -subcutaneous heparin
- -oral (rivaroxaban, pradax)
- Catheter-directed thrombectomy
Long-term management of VTE
- - warfarin (standard tmt)
- - LMW heparin
- - oral inhibitors (rivaroxaban, pradax)
Describe who is the universal RBC donor, the universal serum and platelet donor
- RBC: O negative
- serum and platelet: AB positive (no antibodies)
When to transfuse RBCs
- Hb < 70 (almost always)
- 70-100: if there is impaired oxygen delivery
- >100 inappropriate except in special circumstances
When to transfuse platelets
What is in PCC (prothrombin complex cencentrations)
- - Vit K dependent factors
- - protein C and S
indications for transfusing PCC
- DO transfuse: major surgery or urgent surgery with warfarin therapy OR vit K deficiency and INR>1.5
- Dont transfuse in patients with heparin induced thrombocytopenia (HIT)
Difference between coagulation and platelet disorders (also called secondary and primary hemostasis disorders)
- Think that coagulation disorders dont let blood into the fine areas like mucous membranes.
basic evaluation of chronic ITP
- Hx: isolated bleeding and drug history
- PE: no hepatosplenomegaly, lymphadenopathy, or congenital condition
- CBC: isolated thrombocytopenia
- PBS: normal to large platelets
Describe the treatment of DIC
- -treat underlying condition
- -FFP to replenish clotting factors
- -protein C
- -platelet replacement if critical
Tmt of ITP
First line: IV gamma globulins; steroids; anti-Rh
What are the 5 things that characterize TTP
- 1) consumptive thrombocytopenia
- 2) non-immune hemolytic anemia
- 3) fever
- 4) focal neurological symptoms
- 5) renal impairment
Describe the lab results you expect to see with vWD
- normal INR/PT
- usually prolonged PTT
- prolonged bleeding time
Describe how liver disease affects bleeding
- 1) reduced production of involved proteins
- 2) reduced clearance of involved factors
- 3) impaired control of fibrinoloysis
- 4) impaired platelet function
- 5) portal hypertension: splenomegaly, esophageal varices
- 6) vit K issues
Describe the coag lab results you would expect to see with liver failure
- -INR extends first because of the short 1/2 life of factor VII
- -PTT then extends
- -fibrinogen, D-dimer, thrombin time are usually normal until very severe
- -use factor V to differentiate between vit K and liver problems, low factor V is a bad liver
What does DDAVP do?
Releases stores of vWF and VIII, works in minutes!
What are humate, recombinate, benefix, and prothrombin complex concentrate (PCC)
- humate: vWF and VIII
- recombinate: VIII
- benefix: IX
- PCC: II, VII, IX, X
What is the triad of HUS and pentad of TTP
HUS: Hemolytic anemia, uremia, thrombocytopenia
TTP: HUS + fever, neurological findings (FAT RN: fever, anemia, thrombocytopenia, Renal probs, neurological)
Describe the coagulation cascade
What is in cryoprecipitate?
- major: factor VIII and fibrinogen
- minor: factor XIII, vWF, fibronectin
better source of major components than Fresh Frozen Plasma (FFP)
What does vWD VERY similar to?
a platelet deficiency
How would you differentiate between DIC and TTP? (3 categories)
- DIC: elevated D-dimer, decreased fibrinogen, decreased clotting factors
- TTP: normal D-dimer, fibrinogen, and clotting factors
What are the 3 causes of microangiopathic hemolytic anemia?
HUS, TTP, DIC
DICk's HoUSe got TTP'd
Briefly describe what is happening in DIC, HUS/TTP, and ITP.
- DIC: fibrin deposit in small BV's
- HUS/TTP: microemboli of platelets
- ITP: IgG directed against platelets
What is the best treatment for hemophilia?
Factor Replacement. Either recombinant or plasma derived.
What are the two purposes of factor VIII?
- 1) increases rate of cleavage of factor X by activated factor IX
- 2) is a carrier protein of vWF (and vice versa)
Draw the coagulation cascade
Describe the 3 phases of hemostasis
- 1) primary hemostasis: vasc response and platelet plug formation via vWF
- 2) secondary hemostasis: fibrin clot formation
- 3) resolution: fibrinolysis
What are the common ages in TTP and HUS?
What should you suspect in all women with menorrhagia?
Which coagulation factors are produced in the liver?
all of them except factor VIII (made in the vascular endothelium)
Descibe what happens to the factor V, VII, VIII levels in liver disease, vit K deficiency, and DIC
Common causes of hypercoag.
- AS CALM
- Antiphospho Ab
- Protein S deficiency
- Protein C Deficiency
- Antithrombin deficiency
- Factor V Leiden
Describe how well's criteria is used for venous thrombosis?
- If clinical picture is unlikely for DVT:
- -do D-dimer assay-> if less than 500 then rule out PE, if greater than 500 do CT
- If clinical picture is likely for DVT:
- -do CT (this is the gold standard for ruling in/out)