Bleeding disorders

Question 1

WHat are the uses of tranexamic acid?

Answer 1

An antifibrinolytic that is used to prevent or treat bleeding associarted with excessive fibrinolysis, e.g, surgery, dental extraction, obsteric disorders, menorrhagia, hereidatry angioedema, epistaxis, thrombolytic overdose.

Question 2

What is desmopressin used for?

Answer 2

Mild-mod haemophilia, von willebrand disease, firbonytic response testing.

Question 3

What patients are at high risk of a VTE when admitted to hospital?

Answer 3

Anticipated to have a substantial reduction in mobility, obesity, malignant disease, history of VTE, thrombophilli disorder, 60+ years.

Question 4

What VTE prophylaxis is preferred in renal failure pts?

Answer 4

Heparin (unfractioned)

Question 5

How long should VTE pharmacological prophylaxis be used for in general surgery and major surgery?

Answer 5

5-7 days until mobility has been re-established for general surgery and 28 days after a major surgery such as cancer, hip or knee surgery.

Question 6

What is the inital treatment of a VTE

Answer 6

LMWH or unfractioned heparin, as IV loading dose followedby continuous IV infusion or intermittent SC.

Question 7

When should warfarin be used in VTE?

Answer 7

Immediately with heparin IV doses until INR stabilised to >2 for atleast 24 hours, hpearins should be used for atleast 5 days until maintenance dose of warfarin is achieved.

Question 8

What VTE should be used in pregnancy?

Answer 8

Heparins, as they do not cross the BBB, LMWH are preferred because they have a lower risk of osteoporosis and induced thrombocytopenia, higher doses are required as they are eliminated more rapidly in pregnancy.

Question 9

What should you do if a haemorrhage occurs whilst taking heparins?

Answer 9

In most cases withdrawal of heparin is sufficient, if rapid reversal is required protamine sulfate can be used which is a specific antidote.

Question 10

What is given to a patient suffering from a suspected TIA?

Answer 10

Aspirin or if CI then clopidogrel

Question 11

What is the maximum time frame for alteplase to be administered following a stroke?

Answer 11

4.5 hours, to be administered by trained medical staff preferably in a specialist stroke centre

Question 12

When should aspirin be initiated following thrombolysis?

Answer 12

24 hours after thrombolysis or asap (within 48 hours of onset of symptoms) if not receiving thrombolysis

Question 13

True or false. Anticoagulants can be used as an alternative to antiplatelets in stroke management?

Answer 13

False, not recommended as alternatives

Question 14

What long term treatment is recommended following a TIA or ischaemic stroke?

Answer 14

Clopidogrel (unlicensed in TIA) long-term, or a combination or monotherapy of dipyridamole or aspirin if either \both CI or intolerable.
Stain initiated 48hrs after symptoms of stroke irrespective of serum cholesterol concentrations.
Hypertensive treatment following the acute phase with a target of <130/80 (b blockers not to be used unless indicated for coexisting condition
Lifestyle changes to diet, exercise, weight, alcohol and smoking.

Question 15

How does long term management following a stroke differ to a pt with AF?

Answer 15

Anticoagulants for long term prevention

Question 16

How does long term management differ in intracerebral hemorrhage?

Answer 16

Anticoagulants not recommended even if pt has AF, unless at high risk of an event. Aspirin only given in high risk of cardiac events. BP should be monitored and treated appropriately. Stations to be avoided unless risk of vascular event outweighs risk of further haemorrhage.

Question 17

What are anticoagulants used for?

Answer 17

Prevent thrombus formation in the venous side of circulation

Question 18

Why are anticoagulants more effective in veins rather than arteries?

Answer 18

Thrombi in the veins consist of fibrin web enmeshed with platelets and RBC. In the arteries thrombi have little fibrin.

Question 19

How long does it take for warfarin effects to develop fully?

Answer 19

48-72 hours. Heparins to be used concomitantly for

Question 20

Target values rather than ranges are now recommended.

Answer 20

INR 2.5 for: tx of DVT or pulmonary embolism, AF, cardioversion, dilated cardiomyopathy, mitral stenosis
INR3 .5 for: recurrent DVT or pulmonary embolism.

Question 21

An INR of 3 is recommended for pt with prosthetic heart valve?

Answer 21

False. INR differs on type and location of valve.

Question 22

How long should anticoagulants be used for following a DVT?

Answer 22

6 weeks for isolated calf vein DVT. 3 month for provoked or with transient risk factors (contraceptive, pregnancy, long haul flights), at least 3 months for unpro

Question 23

In the event of a patient taking warfarin suffering a major bled what is the most appropriate action to take?

Answer 23

Stop warfarin, give vit K by slow IV, give dried prothrombin complex or fresh frozen plasma if unavailable.

Question 24

Pts on warfarin are advised to stop warfarin 5 days before elective surgery, if a pt is at high risk of thromboembolism what is recommended?

Answer 24

Stop warfarin and use LMWH until 24 hours before surgery. Warfarin can be resumed next day.

Question 25

What should be given to warfarin pts in an emergency surgery?

Answer 25

If surgery can be delayed for 6-12 hours but I can be given iv but if not dried prothrombin complex and vit k.

Question 26

Which type of heparin has longer duration of action?

Answer 26

LMWH, used routinely but for pts at high bleeding risk unfractioned can be usedas its effects can be stopped by removing the infusion.

Question 27

Heparin induced thrombocytopenia (low levels of platelets) is a risk of administering heparin. What type of heparin has a lower risk of HIT?

Answer 27

LMWH, they are the preferred heparin for prevention of VTE as they are as effective and have a lower risk of HIT.

Question 28

Can you give an antiplatelet and anticoagulant ntogether?

Answer 28

Yes, should be used for minimal amount of time.

Question 29

What is the MOA of fondiparinux?

Answer 29

Inhibits activated factor x

Question 30

When can clopidogrel and aspirin be used?

Answer 30

STEMI, NSTEMI, percutaneous coronary intervention, atherothrombotic and thromboembolic events in AF pts

Question 31

What is the recommended treatment length for aspirin and clopidogrel in a STEMI and a NSTEMI?

Answer 31

STEMI: at least 4 weeks, optimum treatment duration has not been established. NSTEMI: up to 12 months

Question 32

What is an alternative to low dose aspirin and why would a switch be considered?

Answer 32

Clopidogrel, if hypersensitive or intolerable even with PPI

Question 33

What alternatives can be given for clopidogrel in pts undergoing PCI?

Answer 33

Prasugrel or ticagrelor

Question 34

What effects would you see in an aspirin overdose?

Answer 34

Hyperventilation, tinnitus, deafness, vasodilation, sweating. Coma indicates very severe

Question 35

You receive a prescription for a 34yr old male for aspirin, no strength has been stated and the directions are ASD. What strength of aspirin do you give?

Answer 35

BP directs that when no strength has been stated, 300mg should be prescribed

Question 36

What factor does rivaroxoban, apixiban, edoxoban inhibit?

Answer 36

Factor xa

Question 37

What monitoring should be taken in pts recieving heparin?

Answer 37

Platelet count before treatment and regularly if given long term. Potassium plasma concentrations before and regularly in pts at risk of hyperkalemia (diabetes, renal failure, acidosis, taking k supps)

Question 38

When should you treat a patient with stage 1 hypertension?

Answer 38

Stage 1=clinical BP of +140/90 in clinical setting and +135/85 ambulatory/home BP monitoring. Treat patient under 80 and have target organ damage (LVH, CKD, HT retinopathy) CV disease, renal disease, diabetes, 10 year cv risk >20%. Absence of these conditions advise lifestyle changes and review annually.

Question 39

When should you treat a pt with stage 2 HT?

Answer 39

Stage 2=clinic blood pressure 160/100, +160/90 ambulatory/home monitoring, treall all pts.