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Flashcards in Approach to the Bleeding Patient Deck (31):
1

How do you calculate INR?

PT (patient) divided by PT (mean normal)
Raised to exponent (ISI)

PT=prothrombin time

2

What are 5 ways liver disease affects clotting?

Vitamin K deficiency
Thrombocytopenia
Decreased production of clotting factors
Dysfibrinogenemia
Increased fibrinolytic activity

3

What are the results of inappropriate thrombin generation in DIC?

1. thrombocytopenia
2. drop in fibrinogen
3. decrease in factors (particularly V/VIII)
4. Low levels of antithrombin III and Protein C
5. Secondary fibrinolysis

4

Causes of DIC?

Infection
Malignancy
Obstetric complications

5

Treatment of DIC

1. Identify and treat the underlying cause
2. Fresh frozen plasma
3. Platelets
4. Antithrombin III concentrates
5. Activated protein C concentrates

6

What are 5 symptoms of Thrombotic thrombocytopenic Purpura (TTP)?

1. Microangiopathic hemolytic anemia
2. Thrombocytopenia
3. Mental status changes
4. Renal insufficiency
5. Fever

7

What are 6 diagnostic indicators of TTP?

1. Schizocytes on PBS
2. Thrombocytopenia
3. Markedly elevated LDH
4. Increased indirect bilirubin
5. Decreased ADAMTS13
6. Antibody to ADAMTS13

8

Treatment of TTP?

Plasma exchange
Fresh frozen plasma
Steroids
Rituximab

9

Do NOT treat TTP with:

platelets

10

Differential diagnosis of microangiopathic hemolytic anemia and thrombocytopenia?

TTP
Hemolytic uremic syndrome (HUS)
HELLP syndrome
DIC
SLE
Malignant hypertension

11

If there is a low platelet count + bleeding, what are the 3 lab tests you are going to order?

1. BM examination (production prob)
2. Platelet Abs (ITP)
3. Screening test for DIC

12

If there is a normal platelet count + bleeding, what are the 4 tests you want to order?

1. PT and PTT (clotting factors)
2. Platelet aggregation studies with ADP, epi, collagen
3. Other platelet tests (adhesion molecules)
4. vWF and Factor VIII assays

13

What lab test distinguishes between vWF disease and hemophilia?

vWF assay: both will have low Factor 8 but vWF disease will also have low vWF

14

What is a correction/inhibitors test? Explain the results

pt plasma mixed with normal plasma and do a PPT

normal PPT= could be factor deficiency
abnormal PPT = patient has an inhibitor (Ab against a factor)

15

T of F: Aspirin will affect a platelet function analysis

T

16

What can cause a long platelet function analysis performed with epi and ADP?

vWF disease or platelet dysfunction

17

What test do you perform to check if anti-platelet drugs are working?

platelet aggregation study

18

What is the therapeutic range for INR?

2-2.5

19

Why do we use INRs?

A way to compare bleeding across all labs
(human brain vs rabbit brain used for thromboplastin)

20

What is the definition of disseminated Intravascular Coagulation?

inappropriate generation of thrombin

21

For a pt with DIC will the following be normal, low, or high?

fibrinogen
PTT
PT
platelet count
factor 5 and 8
anti-thrombin 3
protein C
fibrinolysis

fibrinogen: low
PTT: high
PT: high
platelet count: low
factor 5 and 8: low
anti-thrombin 3: low
protein C: low
fibrinolysis: high

22

Why do you see peripheral gangrene in DIC?

clotting off capillaries

23

T or F: in DIC, pt can bleed and get thrombosis at the same time

T

24

What treatment for DIC directly blocks the action of thrombin?

anti-thrombin 3 concentrate

25

Who is most likely to get TTP?

women 20-40s

26

What are the 3 signs/symp of TTP?

MAHA
thrombocytopenia
mental status changes (TIA, stroke, headache, irritable)

27

What is the pathogenesis of TTP?

Ab to ADAMTS13 = vWF multimer does not get cleaved--> causes platelet aggregates in microcirculation --> RBCs try to get past them and are fragmented (schistiocytes formed) --> more and more capillary beds are involved

28

What is the function of ADAMTS31?

protease that cleaves vWF multimers to be the correct size

29

T or F: the presnece of the ADAMTS31 Ab is the lab value you need to confirm Dx and begin Tx.

F: if you wait until you get the Ab results the pt will be dead

30

What is the most effective Tx for TTP?

plasma exchange + immunosupressants bc 40% will relapse

31

Why do you not give a TTP pt platelets?

they will cause them to stroke