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harsha-bleeding disorders Flashcards

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1
Q

What are 5 components of haemostasis

A
  • blood vessels and endothelial cells
  • platelets
  • coagulation factors
  • coagulation inhibitors
  • clot dissolution or fibrinolysis
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2
Q

Describe primary haemostasis

A
  • damaged vessel narrows to contract lumen
  • platelets activated
  • adhere and clump to form a platelet plug to seal defect
  • clumped activated platelets secrete chemicals to recruit more platelets to aggregate and become activated
  • trigger coagulation pathway
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3
Q

Describe secondary haemostasis

A
  • sequential activation of a cascade of otherwise inert pro-enzymes in the plasma-results in a stronger, stable fibrin clot (made from thrombin)
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4
Q

Describe regulation of coagulation and fibrinolysis

A
  • Coagulation needs to be confined to the site of injury to prevent venous and arterial thrombosis
  • The balance is obtained by naturally occuring coagulation inhibitors
  • when clotting occurs to seal an injury, the fibrinolytic system is activated simultaneously which allows timely clot breakdown and re-canalization to maintain continuity of circulation
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5
Q

What are the 6 steps of blood circulation and haemostasis

A
  • injury and haemorrhage
  • vascular contraction
  • platelet adhesion, aggregation, activation
  • coagulation
  • fibrinolysis
  • recanalization/restoration of bloodflow
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6
Q

What are 4 types of bleeding disorders

A
  • vascular defects
  • platelet disorders
  • coagulation disorders
  • increased fibrinolysis
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7
Q

what are some causes of vascular defects

A
  • age
  • long-term steroid use
  • hereditary haemorrhagic telengiectasia
  • scurvy
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8
Q

what are some classes of platelet disorders

A
  • inherited thrombocytopenia
  • myeloproliferative disorders
  • bone marrow failure (infection, immunologically mediated)
  • Drug induced
  • Platelet function disorders
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9
Q

What are some coagulation disorders

A
  • von-willebrand disease
  • haemophilia A
  • haemophilia B
  • Vitamin K deficiency
  • Liver disease
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10
Q

What is the condition associated with increased fibrinolysis

A

Disseminated intravascular coagulation (DIC) (often fatal)

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11
Q

What are some therapeautic anticoagulants that cause bleeding disorder

A
  • antiplatelet drugs
  • coumarin anticoagulants
  • NOACs
  • Heparin
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12
Q

Describe the two types of platelet disorder

A

Thrombocytopenia (reduced numbers)
- decreased production
- decreased survival
- increased consumption
Defective function
- Glanzmann’s thrombasthenia
- Aspirin
- NSAIDs
- Anti-platelet drugs

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13
Q

what is the normal platelet count and at what platelet count may the patient experience spontaneous bleeding

A
  • 150000-400000/ml
  • less than 20000/ml
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14
Q

Describe spontaneous bleeding due to low platelet count (skin)

A

superficial bleeding in skin and mucoase
- petichiae
- purpura
- ecchymosis

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15
Q

What is epistaxis

A

nose bleeding

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16
Q

What is haemoptysis

A

coughing up blood

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17
Q

what is haematemisis

A

vomiting blood

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18
Q

what is haematuria

A

blood in urine

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19
Q

Orally, what may platelet defects present as

Study These Flashcards
A
  • Bleeding gums
  • Prolonged bleeding after injury/extractions
20
Q

What are coagulation disorders characterised by

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A
  • prolonged bleeding
  • severe and often life threatening
  • can bleed into deep tissue
  • occurs as a result of deficiency of coagulation factors which can be acquired or congenital
21
Q

What are congenital coagulation disorders

Study These Flashcards
A
  • Haemophilia A- factor 8 deficient
  • Haemophilia B- factor 9 deficient
  • von-willebrand disease
22
Q

What are acquired coagulation disorders

Study These Flashcards
A
  • acquired antibodies to f-VIII
  • vit K deficiency
  • liver disease
23
Q

How are coagulation disorders managed preventatively

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A

carefully managed preventative dental care to avoid/minimise need for dental procedures

24
Q

Describe haemophilia

Study These Flashcards
A

sex linked recessive transmission, affects males but females can also be carriers. Range of severity from mild to severe

25
What are some considerations for haemophiliacs
- need close monitoring by specialist haematologists - need coagulation factor supplements to manage daily activities and remain free from incapacitating disabilities - run the risk of acquiring blood borne cross infections
26
What are some coagulation factor replacements
- Fresh whole blood - fresh frozen plasma - platelet concentrate - cryoprecipitate - human or bovine factor concentrate - recombinant factor- ideal
27
Describe von willebrand disease
- most common inherited anticoagulation disorder - occurs due to vWf deficiency which promotes platelet adhesion and carries factor 8 in plasma
28
What are some symptoms of von willebrand disease
- bruising - mucosal bleeds - prolonged bleeding after trauma
29
How are von willebrand patients managed (mild and severe)
mild- anti-fibrinolytic agents or with DDAVP severe- factor 8 replacement therapy
30
Describe liver disease and bleeding
- most coagulation factors produced in liver - necrosis of liver cells (hepatitis or alcohol) results in failure of coagulation factor synthesis-> severe bruising or bleeding
31
How is bleeding disorder due to liver disease managed
- factor replacement therapy and addressing the cause of the liver disease
32
Describe vit K deficiency and bleeding disorder
- either dietary deficiency or the result of a range of gut and pancreas disorders, or obstructive biliary tract disease - depletion of vit k dependent factors
33
How can vit K deficiency be treated
- injection will reverse biochemical lesion in malabsorption but will not be effective if there is severe liver cell necrosis - coumarin anticoagulants antagonise vitk action
34
Describe diagnosis of bleeding disorders
taking a good history - excessive bleeding following trauma? - family history - drug therapy - skin and mucosal bleeding - epistaxis, haemoptysis, haematemesis, haematuria signs and symptoms investigations
35
What are some investigations of bleeding disorders
- bleeding time - full blood count (platelet count) - blood picture (maturation prob?) - prothrombin time/INR (inr 1 norm) - APTT or KCCT - diluted thrombin time - FDP assay - Individual factor assay
36
What are therapeutic anticoagulants used for
Reducing thromboeembolic risk in patients with underlying medical diseases
37
What conditions might be prescribed anticoagulants
- atrial fibrillation - prosthetic heart valves - coronary artery disease - myocardial infarction - heart failure - DVT - pulmonary embolism - cerebero-vascular disease
38
What are some anti-platelet drugs
- Aspirin - Dipyridamole - Clopidrogel
39
What are some anticoagulant drugs
- Heparin - Streptokinase - Warfarin - Dabigatran - Rivaroxaban - Apexiban
40
What anticoagulants are NOACs?
- Dabigatran - Rivaroxaban - Apexiban
41
Describe warfarin and approach
- most commonly used anticoagulant - inhibits action of vit K - needs careful monitoring with INR - should carry an anticoagulant card
42
What may potentiate warfarin and increase INR
- Azoles - Omeprazole - Paracetamol - Erythromycin - Metronidazole - Broad spectrum antibiotics - st johns wart - cranberry juice - grapefruit juice - large amts of alcohol
43
Describe NOACs
Novel oral anticoagulants direct thrombin inhibitors: - dabigatran factor Xa inhibitors: - rivaroxaban - apixaban - endoxaban - betrixaban these are no longer maintained by INR Idaracizumab can be used to reverse dabigatran
44
What are some clinical implications of NOVACs
- less drug interactions - shorter half life - increasing use in clinical practice - easier to manage in the dental setting as can consider delaying day's dose due to shorter half life
45
What can increase vit-k and reduce INR
- liver - broccoli, brussel sprouts, leafy greens
46
Describe management of bleeders
- most common cause of post op haemmorhage is excessive soft tissue trauma - history of prev episodes is a valuable cue - pts with bleeding risks should be managed with input from specialists - be alert to other medical disorders, cross infection risks, concurrent drug therapy - do not stop anticoagulant medication without approval from pt's physician - preventative dental health is important to avoid life threatening risks.

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