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Describe Virchow's Triad
Thrombosis is due to stasis, vessel wall injury, hypercoag in isolation or in combination with eachother
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predisposing factors for VTE
- -Surgery
- -co-morbidities: Ca, COPD, HITT, IBD, others
- -pregnancy
- -Rx: the pill, HRT, tamoxifen, thalidomide
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Two types of acquired thrombophilia
- anticardiolipin (ACL) Ab
- Lupus anticoagulant Ab (LUPAC)
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4 symptoms and 4 signs of acute PE
symptoms: dyspnea, pleuritic chest pain, cough, hemoptysis
Sign: tachypnea, rales, tachycardia, 4th heart sound
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Short term management of VTE
- Drugs:
- -IV heparin
- -subcutaneous heparin
- -oral (rivaroxaban, pradax)
- Catheter-directed thrombectomy
- Thrombolysis
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Long-term management of VTE
- - warfarin (standard tmt)
- - LMW heparin
- - oral inhibitors (rivaroxaban, pradax)
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Describe who is the universal RBC donor, the universal serum and platelet donor
- RBC: O negative
- serum and platelet: AB positive (no antibodies)
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When to transfuse RBCs
- Hb < 70 (almost always)
- 70-100: if there is impaired oxygen delivery
- >100 inappropriate except in special circumstances
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When to transfuse platelets
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What is in PCC (prothrombin complex cencentrations)
- -concentrated
- - Vit K dependent factors
- - protein C and S
- -heparin
- -antithrombin
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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)
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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.
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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
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Describe the treatment of DIC
- -treat underlying condition
- -FFP to replenish clotting factors
- -protein C
- -platelet replacement if critical
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Tmt of ITP
First line: IV gamma globulins; steroids; anti-Rh
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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
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Describe the lab results you expect to see with vWD
- normal INR/PT
- usually prolonged PTT
- prolonged bleeding time
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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
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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
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What does DDAVP do?
Releases stores of vWF and VIII, works in minutes!
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What are humate, recombinate, benefix, and prothrombin complex concentrate (PCC)
- humate: vWF and VIII
- recombinate: VIII
- benefix: IX
- PCC: II, VII, IX, X
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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)
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Describe the coagulation cascade
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What is in cryoprecipitate?
major (2)
minor(3)
- major: factor VIII and fibrinogen
- minor: factor XIII, vWF, fibronectin
better source of major components than Fresh Frozen Plasma (FFP)
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What does vWD VERY similar to?
a platelet deficiency
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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
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What are the 3 causes of microangiopathic hemolytic anemia?
HUS, TTP, DIC
DICk's HoUSe got TTP'd
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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
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What is the best treatment for hemophilia?
Factor Replacement. Either recombinant or plasma derived.
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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)
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Draw the coagulation cascade
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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
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What are the common ages in TTP and HUS?
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What should you suspect in all women with menorrhagia?
vWD
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Which coagulation factors are produced in the liver?
all of them except factor VIII (made in the vascular endothelium)
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Descibe what happens to the factor V, VII, VIII levels in liver disease, vit K deficiency, and DIC
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Common causes of hypercoag.
- AS CALM
- Antiphospho Ab
- Protein S deficiency
- Protein C Deficiency
- Antithrombin deficiency
- Factor V Leiden
- Malignancy
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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)
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