Nikcevich- Clincal Cases in Coagulation

Question 1

What is a normal platelet count?

Answer 1

150-400,000

Question 2

What happens if the platelet count is 25,000

Answer 2

Probably nothing

Question 3

What happens if the platelet count is <10,000

Answer 3

Increased risk of mucocuntaneous bleeding and CNS hemorrhage

Question 4

What is more important in regards to platelets than the actual number of platelets?

Answer 4

Platelet surface area

Question 5

What is the most common reason for impaired platelet function?

Answer 5

Aspirin

Question 6

INR is used to usually monitor what drug?

Answer 6

Warfarin efficacy

Question 7

What is the target INR?

Answer 7

2-3.5

Question 8

What does PTT measure?

Answer 8

heparin efficacy

NOT LMW heparin

Question 9

What is the single worse clinical test available?

Answer 9

Bleeding time

was designed to measure platelet function

Question 10

What is the most common cause of increased bleeding time?

Answer 10

Aspirin

Question 11

What does Aspirin do?

Answer 11

Irreversibly acetylates platelets

Question 12

How long does aspirin’s effects last for?

Answer 12

Up to 10 days

Question 13

How do you reverse aspirin?

Answer 13

Wait 10 days and see if you can give platelets

Question 14

What do ibuprofen, naproxen, etorolac, sulindac and indomethacin do?

Answer 14

Reversibly effect platelet function

**effects can be reversed w/in 6-8 hrs

Question 15

What is the most common anti-coagulant?

Answer 15

Warfarin

Interferes w/ vit K dep secondary glycosylation of factors 2,7,9,10

Question 16

How is warfarin dosed?

Answer 16

Accodring to INR

Question 17

What is the biggest disadvantage of Warfarin?

Answer 17

It has a lot of drug interactions

Question 18

How do you reverse warfarin?

Answer 18

Time
vit K
Fresh frozen plasma

Question 19

What type of heparin has the most reliable absorption?

Answer 19

LMWH- no need to monitor levels

Unfractionated has UNPREDICTABLE absorption–need to monitor daily w/ PTT

Question 20

When is clopidogrel used?

Answer 20

After cardiac stents/ stroke

Question 21

What does tPA do? When is it used?

Answer 21

Responsible for direct fibrinolysis.

MI, stroke, PE

Question 22

What does vit K do?

Answer 22

Reverses effects of warfarin

often helpful w/ coagulopathy of liver disease

(phytadione)

Question 23

What does DDAVP do?

Answer 23

Increases vWF prodcution

Question 24

What does fresh frozen plasma do?

Answer 24

Gets all coagulant factors to normal levels

can reverse warfarin effects/replace factors missing d/t liver disease/DIC

Question 25

What does cryprecipitate do?

Answer 25

Provides fibrinogen, VWF, facotr 8 and 13, fibronectin

Question 26

What is commonly sen w/ platelet defects?

Answer 26

Prolonged bleeding petechiae and easy bruising skin and mucous membranes non-recurrent bleeding

Question 27

What is seen w/ coagulation defects?

Answer 27

pro-longed bleeding deep hematomas recurrent bleeding

Question 28

What do you think when you see an elevated PTT?

Answer 28

Heparin? Lupus-anticoagulant or antiphospholipid Ab? Liver disease

Question 29

How do you diagnose a problem from a prolonged PTT?

Answer 29

Do a mixing study corrects- lab error, heparin contamination don't correct- LAC or inhibitor

Question 30

What are causes of prolonged INR?

Answer 30

Warfarin use- most common anti-phospholipid ab liver disease malnutrition (vit K def)

Question 31

How do you determine the cause of prolonged INR?

Answer 31

Mixing study corrects-- lab error/factor def doesn't correct-- anti-phospholipid ab or inhibitor

Question 32

What can cause thrombocytosis?

Answer 32

Increased platelets can be caused by secondary processes like IDA or primary processes like a myeloproliferative disorder

Question 33

How long should a pt w/ uncomplicated non-life-threatening DVT/PE be given Warfarin?

Answer 33

At least 6 months of warfarin w/ target INR 2-3

Question 34

How long should you treat someone with life-threatening DVT/PE/arterial thrombosis?

Answer 34

indefinite anticoagulation

Question 35

How long should you treat a second DVT/PE that isn't life threatnening?

Answer 35

Indefinitely

Question 36

How long should you treat an uncomplicated first DVT/PE in someone who is homozygous for an inherited coagulopathy?

Answer 36

indefinitely

Question 37

How long should you treat an uncomplicated first DVT/PE in someone who is heterozygous for an inherited coagulopathy

Answer 37

At least 6 mos w/ target INR 2-3 or longer

Question 38

What does an IVC filter do?

Answer 38

Traps any PE. Most frequently used in preoperative pt w/ increased risk for DVT/PE Requires anti-coagulation

Question 39

Why do you bridge w/ heparin?

Answer 39

Because many pro-coagulant factors have a longer half life than protein C. Factor III t 1/2 = 60 hrs F VII= 6 hrs Protein C t1/2 = 9 hrs

Question 40

What is a surrogate marker for low prot C?

Answer 40

HIGH INR low factor VII

Question 41

A pt who is managed w/ warfarin develops epistaxis and has an INR of 10. What do you order for them?

Answer 41

2 mg PO x1 of Vit K

Question 42

How do you treat ITP- immune mediated thrombocytopenia?

Answer 42

Prednisone at 1mg/kg daily Pulse dexamethasone 40 mg po qdx4d Very common- low platelets

Question 43

How do you treat a pt who has ITP and a platelet count of 65k?

Answer 43

Observe w/ serial monitoring