True Learn: Hematology & Coagulation

Question 1

Which of the following is NOT one of the components of the 4T score for heparin-induced thrombocytopenia?
A. Platelet count
B. Presence of thrombosis
C. Thrombin level
D. Timing of hematologic changes

Answer 1

C. Thrombin level

Question 2

You are caring for a patient who needs an intra-operative blood transfusion due to ongoing hemorrhage. The patient has intermittent hypotension but still responds to intravenous fluid boluses. Lab results show that the patient has a positive antibody screen and no compatible units are available. Which of the following is the MOST reasonable management of the patient?
A. Administer O-negative blood
B. Administer type-specific blood
C. Call the blood bank to determine the specific antibody present
D. Withhold a transfusion until compatible units are available

Answer 2

C. Call the blood bank to determine the specific antibody present

Question 3

A 6-month-old term 8 kg infant undergoes emergent exploratory laparotomy for bleeding after a car accident. The starting hematocrit is 40%. If packed red blood cell transfusions are to begin at a target hematocrit of 20%, which of the following BEST represents the maximum allowable blood loss range?
A. 140-210 ml
B. 280-425 ml
C. 440-595 ml
D. 565-640 ml
E. 685-755 ml

Answer 3

B. 280-425 ml

Question 4

Which of the following is a source of tissue hypoxia from carbon monoxide poisoning?
A. Increased coupling of oxidative phosphorylation
B. Left shift of the oxygen hemoglobin dissociation curve
C. Increased ATP production
D. Reduced anaerobic metabolism

Answer 4

B. Left shift of the oxygen hemoglobin dissociation curve

Question 5

Which of the following will lead to increased oxygen delivery?
A. Increased hemoglobin
B. Increased systemic vascular resistance
C. Decreased cardiac preload
D. Decreased cardiac contractility

Answer 5

A. Increased hemoglobin

Question 6

Which of the following is NOT a risk factor for heparin resistance?
A. Antithrombin III levels < 60% of normal
B. Platelet count < 150,000/mm^3
C. Preoperative heparin therapy
D. Use of low molecular weight heparin

Answer 6

B. Platelet count < 150,000/mm^3

Question 7

The administration of fresh frozen plasma in a patient on warfarin is MOST appropriate in which of the following scenarios?
A. Elective cataract surgery with INR of 3.0
B. Emergent exploratory laparotomy with INR of 1.3
C. Femur fracture open reduction internal fixation that needs to proceed within 48 hours with INR 2.5
D. Urgent ruptured appendectomy with INR of 2.1

Answer 7

D. Urgent ruptured appendectomy with INR of 2.1

Question 8

A 57-year-old male with end-stage-liver-disease (ESLD) is undergoing an orthotopic liver transplant. You order thromboelastography (TEG) due to ongoing surgical bleeding. Which of the following products would be MOST HELPFUL in correcting a low MA value (Maximal Amplitude)?
A. Cryoprecipitate
B. Fibrinogen
C. FFP
D. Platelets

Answer 8

D. Platelets

Question 9

A 33-year-old female with Marfan syndrome and a history of heparin induced thrombocytopenia type 2 is undergoing an emergent aortic arch repair. In the setting of normal preoperative renal function, which of the following is the BEST choice for intraoperative anticoagulation while undergoing cardiopulmonary bypass?
A. Hirudin
B. Low molecular weight heparin
C. Ancrod
D. Bivalirudin

Answer 9

D. Bivalirudin

Question 10

A 47-year-old trauma patient with multiple injuries arrives in the operating room for external fixation of his pelvis. He has received 2 units of packed red blood cells and 3 liters of crystalloid. A computed tomography scan revealed significant blood accumulating in the pelvis and he continues to be unstable but fluid responsive. Administration of which of the following is the BEST method to reduce dilutional coagulopathy in this patient?
A. Cryoprecipitate
B. Fresh frozen plasma
C. Packed red blood cells
D. Platelets
E. Recombinant factor VIIa

Answer 10

B. Fresh frozen plasma

Question 11

While performing your preoperative evaluation of a 13-year-old female for scoliosis surgery, it is noted that she has no blood products available. The surgeon then asks for a type and crossmatch. Which of the following is NOT a component of a traditional type and crossmatch?
A. Mix patient red cells with anti-A antibodies
B. Mix patient red cells with anti-D antibodies
C. Mix patient serum with donor red blood cells
D. Mix patient serum with known red blood cells
E. Mix patient serum with anti-O antibodies

Answer 11

E. Mix patient serum with anti-O antibodies

Question 12

A 43-year-old male presents to the preoperative clinic for rotator cuff surgery. He states that he has a “bleeding problem” and had a major bleeding episode several years ago. Chart review reveals he has von Willebrand disease type I. Which of the following is the MOST appropriate treatment for this patient prior to surgery?
A. Administration of desmopressin prior to surgery
B. Administration of factor concentrate prior to surgery
C. Fresh frozen plasma prepared in case of surgical bleeding
D. Platelets prepared in case of surgical bleeding

Answer 12

A. Administration of desmopressin prior to surgery

Question 13

Which of the following is NOT one of the potential sequelae of citrate intoxication in the setting of a rapid massive blood transfusion?
A. Myocardial depression
B. Hypermagnesemia
C. Hypotension
D. Hypocalcemia

Answer 13

B. Hypermagnesemia

Question 14

Which of the following is an indication for administering factor VIII concentrate?
A. Massive transfusion
B. Hemophilia A
C. Hemophilia B
D. Hemophilia C

Answer 14

B. Hemophilia A

Question 15

A patient presents to the operating room following a motor vehicle accident that involved fatalities. The patient appears to be in their early 20s. Abdominal ultrasound exam revealed hemoperitoneum. An open book pelvic fracture is diagnosed on physical exam and confirmed by radiograph. Massive transfusion has begun following diagnosis of class IV hemorrhage. Which of the following is MOST likely to result in maintenance of a normal coagulation lab profile?
A. Administration of prothrombin concentrate complex
B. Administration of recombinant factor VIIa early
C. Administration of tranexamic acid
D. Blood therapy utilizing 1:1:1 ratios of packed red blood cells:fresh frozen plasma:platelets

Answer 15

D. Blood therapy utilizing 1:1:1 ratios of packed red blood cells:fresh frozen plasma:platelets

Question 16

Many different physiological changes affect oxygen delivery. Hemoglobin oxygen off-loading occurs more with which of the following?
A. Acidosis
B. Decreased 2,3DPG
C. Fetal hemoglobin
D. Hypothermia

Answer 16

A. Acidosis

Question 17

A 53-year-old female is admitted to the intensive care unit with both arterial and venous thrombosis. Her family states she has a hematological condition called polycythemia vera. Which of the following is associated with this patient’s condition?
A. Heinz bodies in erythrocytes
B. Increased red cell distribution width
C. Microcytic erythrocytosis
D. Thrombocytopenia

Answer 17

C. Microcytic erythrocytosis

Question 18

Which of the following patients would be at the highest risk for perioperative venous thromboembolism?
A. A patient undergoing a total knee arthroplasty
B. A patient with a family history of factor V Leiden disorder
C. A patient with morbid obesity and congestive heart failure
D. A septic patient undergoing an emergent appendectomy

Answer 18

A. A patient undergoing a total knee arthroplasty

Question 19

A 34-year-old patient presents for a seven-level thoracic discectomy and fusion. The surgeon estimates the blood loss will be at least 1.5 liters. The patient is a Jehovah’s Witness with a starting hematocrit of 38%. The patient has obesity and obstructive sleep apnea. Which of the following is TRUE regarding acute normovolemic hemodilution in this scenario?
A. Acute normovolemic hemodilution is not an option given the starting hematocrit
B. The blood will not be maintained in continuity with the patient and thus cannot be used for Jehovah’s Witness patients
C. The collection bag for the blood lacks anticoagulant so there is a higher risk for clotting
D. Units are reinfused to the patient in the reverse order of their withdrawal

Answer 19

D. Units are reinfused to the patient in the reverse order of their withdrawal

Question 20

During a cesarean section, a patient has massive hemorrhage with life-threatening hypotension. They receive 10 units of PRBCs and 5L crystalloid before labs are checked. A thromboelastogram is ordered and the following labs return in the mean time:
Hgb: 10g/dL
Platelets: 50,000 mm^3
Fibrinogen: 200 mg/dL
PT: 10 sec
PTT: 30 sec
Which of the following should be given next?
A. Cryoprecipitate
B. DDAVP
C. Platelets
D. Tranexamic acid

Answer 20

C. Platelets

Question 21

A healthy 32-year-old woman has an arterial blood gas drawn postoperatively which shows a PaO2 of 100 mmHg and hemoglobin of 12 g/dL. Out of the total oxygen in her blood, what percentage of that total is dissolved oxygen?
A. 0.003
B. 0.19
C. 0.3
D. 1.9

Answer 21

D. 1.9

Question 22

Since the year 2000, which of the following is the MOST common cause of mortality from transfusion of blood products in the United States?
A. ABO hemolytic transfusion reactions
B. Non-ABO hemolytic transfusion reactions
C. Transfusion-associated sepsis
D. Transfusion-related acute lung injury

Answer 22

D. Transfusion-related acute lung injury

Question 23

Patients with IgA deficiency who receive blood transfusions are at INCREASED RISK for which of the following?
A. Allergic reaction to antigens in the donor blood
B. Cytokine release activating the complement system
C. Febrile transfusion reactions
D. Graft versus host disease
E. Transfusion associated infections

Answer 23

A. Allergic reaction to antigens in the donor blood

Question 24

Which of the following is the correct biological effect of low molecular weight heparin (LMWH) binding to its target?
A. Hepatic clearance predominates due to increased macrophage binding
B. Platelet binding leads to increased heparin-dependent antibodies compared to heparin
C. Protein binding leads to an unpredictable anticoagulant response
D. Thrombin binding leads to an increased anti-Xa:IIa ratio

Answer 24

D. Thrombin binding leads to an increased anti-Xa:IIa ratio

Question 25

Which of the following would be the expected blood volume of a 30 kg 7-year-old boy?
A. 1800 mL
B. 1950 mL
C. 2200 mL
D. 2500 mL
E. 2700 mL

Answer 25

C. 2200 mL

Question 26

A 34-year-old female with type 1 von Willebrand disease presents for an urgent appendectomy. In order to minimize perioperative bleeding, which of the following is the BEST initial treatment?
A. Desmopressin
B. Factor IX concentrate
C. Fresh frozen plasma transfusion
D. Platelet transfusion

Answer 26

A. Desmopressin

Question 27

Activation of the body’s inflammatory system is the primary mechanism of which of the following embolic syndromes?
A. Air embolism
B. Amniotic fluid embolism
C. Fat embolism syndrome
D. Pulmonary thromboembolism

Answer 27

B. Amniotic fluid embolism

Question 28

Which of the following would result in DECREASED oxygen delivery to the tissues?
A. Cyanide toxicity
B. Dilutional anemia
C. Increased stroke volume
D. Shift of the hemoglobin dissociation curve to the right

Answer 28

B. Dilutional anemia

Question 29

Administration of fresh frozen plasma is NOT recommended for management of which of the following situations?
A. Hemophilia A
B. Major trauma-related blood loss
C. Heparin resistance
D. Thrombotic thrombocytopenic purpura

Answer 29

A. Hemophilia A

Question 30

Which of the following decreases the affinity of hemoglobin for oxygen?
A. Alkalosis
B. Decreased 2,3-bisphosphoglycerate
C. Hypercarbia
D. Hypothermia

Answer 30

C. Hypercarbia

Question 31

Which of the following is NOT an indication for the administration of fresh frozen plasma?
A. Intravascular volume expansion
B. Rapid reversal of warfarin
C. Treatment of heparin resistance due to antithrombin III deficiency
D. Treatment of thrombotic thrombocytopenic purpura

Answer 31

A. Intravascular volume expansion

Question 32

Which of the following is used for treatment of symptomatic acute methemoglobinemia?
A. Amyl nitrate
B. Sodium nitrite
C. Hydroxocobalamin
D. Methylene blue

Answer 32

D. Methylene blue

Question 33

What is the primary mechanism behind delayed hemolytic transfusion reaction?
A. ABO incompatibility
B. Cytokines and antibodies to leukocyte antigens
C. Donor lymphocytes reacting against recipient
D. Donor red blood cell antigens

Answer 33

D. Donor red blood cell antigens

Question 34

A 59-year-old man presents with multivessel coronary artery disease for coronary artery bypass grafting. Which of the following is MOST TRUE regarding the use of antifibrinolytic therapies during surgical cases that require cardiopulmonary bypass?
A. Aprotinin acts as a lysine-analogue by binding to lysine-binding sites on plasminogen
B. The use of aminocaproic acid is associated with decreased rates of perioperative transfusion
C. The use of tranexamic acid is associated with increased rates of postoperative renal dysfunction
D. Perioperative administration of antifibrinolytics has been shown to improve mortality

Answer 34

B. The use of aminocaproic acid is associated with decreased rates of perioperative transfusion

Question 35

Which of the following distinguishes an acute hemolytic transfusion reaction from a delayed hemolytic transfusion reaction?
A. Acute hemolytic reactions are extravascular primarily and delayed reactions are intravascular primarily
B. An acute hemolytic reaction is caused by ABO incompatibility while delayed is due to alloantibodies against smaller antigens such as Rh factor
C. Delayed hemolytic reactions are much more severe
D. Delayed hemolytic reactions require intensive treatment to avoid long term sequelae

Answer 35

B. An acute hemolytic reaction is caused by ABO incompatibility while delayed is due to alloantibodies

Question 36

A 36-year-old male with no past medical history presents after a gun shot wound to the abdomen. Vital signs are blood pressure 80/40 mmHg, heart rate 120 bpm, and a respiratory rate of 30 per minute. Throughout the course of resuscitation, 10 units of packed red blood cells are given. Which of the following derangements is MOST LIKELY to occur given the large amounts of blood products given?
A. Hyperthermia
B. Hypocalcemia
C. Hyperkalemia
D. Metabolic acidosis

Answer 36

B. Hypocalcemia

Question 37

Which of the following is an appropriate choice for management of hemorrhage in a patient with von Willebrand disease?
A. Aminocaproic acid
B. Cryoprecipitate
C. Fresh frozen plasma
D. Recombinant factor VII

Answer 37

B. Cryoprecipitate

Question 38

A patient who has received multiple transfusions over several days for acute blood loss in the setting of lower extremity trauma has a metabolic alkalosis. Which of the following is the most likely cause for this metabolic derangement?
A. Citrate metabolism in the liver
B. Decreased perfusion to kidneys
C. High nasogastric tube output
D. Infusion of multiple bags of normal saline

Answer 38

A. Citrate metabolism in the liver

Question 39

Which of the following patients should be transfused donor red blood cells according to the guidelines recommended by the American Society of Anesthesiologists (ASA)?
A. A healthy adult whose hemoglobin has fallen to 7 g/dL after hip replacement
B. A stable adult undergoing a spinal fusion with a hemoglobin of 7 g/dL with cell salvage available
C. A stable patient with a prior CABG undergoing a hernia repair and a hemoglobin level of 7 g/dL
D. An adult after a trauma with a growing thigh hematoma and a hemoglobin level of 7 g/dL

Answer 39

D. An adult after a trauma with a growing thigh hematoma and a hemoglobin level of 7 g/dL

Question 40

A patient has been receiving enoxaparin for a history of deep vein thrombosis. Which of the following would be the most appropriate test to assess the effectiveness of this anti-coagulation therapy?
A. Anti-Xa assay
B. Bleeding time
C. Partial thromboplastin time
D. Prothrombin time

Answer 40

A. Anti-Xa assay

Question 41

A patient is undergoing coronary artery bypass surgery. Prior to going on bypass 300 units/kg of heparin is administered, but the activated clotting time is only 246 seconds. Additional heparin is given as well as fresh frozen plasma, but the ACT remains below 400 seconds. Administration of which of the following is the next best step in management?
A. Antithrombin III
B. Bivalirudin
C. Desmopressin (DDAVP)
D. Prothrombin complex concentrate (PCC)

Answer 41

A. Antithrombin III

Question 42

Which of the following volume expanding fluids can produce a coagulopathy at large doses?
A. 5% albumin
B. 25% albumin
C. Hydroxyethyl starch
D. Hypertonic saline

Answer 42

C. Hydroxyethyl starch

Question 43

Which of the following patients would MOST benefit from preoperative platelet transfusion?
A. 32 year-old female with platelet count of 99,000/μL undergoing laparoscopic cholecystectomy
B. 36 year-old female with platelet count of 69,000/μL undergoing hysteroscopy
C. 49 year-old alcoholic male with platelet count of 49,000/μL undergoing femoral artery bypass
D. 71 year-old male with platelet count of 119,000/μL undergoing deep brain stimulator placement

Answer 43

C. 49 year-old alcoholic male with platelet count of 49,000/μL undergoing femoral artery bypass

Question 44

A 55-year-old male becomes hypotensive following transfusion of multiple units of packed red blood cells, fresh frozen plasma, and platelets during orthotopic liver transplantation. Flattened T waves and prolonged QT intervals are noted on ECG. Which of the following therapeutic measures would be MOST appropriate at this time?
A. Calcium
B. Insulin
C. Magnesium
D. Normal saline
E. Potassium

Answer 44

A. Calcium

Question 45

A thromboelastogram is done on a patient during a liver transplant for end stage liver disease. The maximum amplitude (MA) is found to be significantly decreased (20 mm). Which of the following is the BEST diagnosis for this patient?
A. Platelet dysfunction
B. Decreased fibrin formation
C. Deficient thrombin formation
D. Hypercoagulable state
E. Clotting factor deficiency

Answer 45

A. Platelet dysfunction

Question 46

A 26-year-old female who is otherwise healthy presented earlier today with fulminant hepatic failure due to an accidental overdose of acetaminophen. The patient is undergoing an orthotopic liver transplantation. During the dissection phase, the portal vein is accidentally injured. The patient becomes acutely hypotensive and receives a total of 10 units of red blood cells and 6 units of fresh frozen plasma. The surgeon is able to repair the IVC and obtain hemostasis. However, the patient continues to be hypotensive despite continued efforts at volume resuscitation. What is the MOST likely source of the patient’s hypotension?
A. Cardiogenic shock
B. Coagulopathy
C. Hemolysis
D. Hypocalcemia

Answer 46

D. Hypocalcemia

Question 47

Which of the following statements regarding P50 of the oxyhemoglobin dissociation curve is TRUE?
A. A 1-year-old child has a higher P50 than an adult
B. Newborns have increased 2,3-DPG resulting in low P50
C. Oxygen affinity for hemoglobin is lowest in adults
D. P50 does not vary with age

Answer 47

A. A 1-year-old child has a higher P50 than an adult

Question 48

Which of the following factors in fresh frozen plasma is the LEAST stable during storage and closely interacts with von Willebrand factor?
A. Factor IV
B. Factor V
C. Factor VI
D. Factor VIII
E. Factor X

Answer 48

D. Factor VIII

Question 49

Which of the following correlations between age and estimated blood volume is CORRECT?
A. Full-term newborn: 80-90 mL/kg
B. Infant 3-12 months old: 95-100 mL/kg
C. Premature infant: 120-130 mL/kg
D. Two-year-old female: 50-55 mL/kg

Answer 49

A. Full-term newborn: 80-90 mL/kg

Question 50

Which of the following is the MOST likely reason for low-grade fevers following packed red blood cell transfusion?
A. ABO mismatch
B. IgE-mediated immune response
C. Citrate intoxication
D. Bacterial contamination
E. Antibodies to human leukocyte antigens

Answer 50

E. Antibodies to human leukocyte antigens

Question 51

A patient had a thoracic epidural placed for postoperative analgesia following gastrectomy. The patient was appropriately started on subcutaneous heparin, 5000 units twice daily during the postoperative period. It is now postoperative day 6 and the epidural catheter is to be removed. In addition to appropriately timed discontinuation of heparin, what else should be considered prior to the removal of the epidural catheter?
A. No further investigation or treatment necessary
B. Obtain a partial thromboplastin time (aPTT)
C. Obtain a platelet count
D. Reversal with protamine, 1 milligram per 100 units of heparin received that day

Answer 51

C. Obtain a platelet count

Question 52

A 22-year-old male with a history of uncomplicated sickle-cell disease is being evaluated prior to an elective tonsillectomy, and his hemoglobin level is found to be 7.5 g/dL. What is the BEST management of his preoperative hemoglobin level?
A. Exchange transfusion
B. Obtain a type and screen and proceed with surgery
C. Transfusion to hemoglobin level of 8 g/dL
D. Transfusion to hemoglobin level of 10 g/dL

Answer 52

D. Transfusion to hemoglobin level of 10 g/dL

Question 53

A thromboelastogram is done on a patient during a liver transplant for end stage liver disease. The R value is found to be significantly prolonged. Which of the following is the BEST treatment for this patient?
A. Fresh frozen plasma
B. Tranexamic acid
C. Cryoprecipitate
D. Platelets

Answer 53

A. Fresh frozen plasma

Question 54

A 76-year-old male was admitted with an acute myocardial infarction. He was found to have a significant stenosis of the left anterior descending artery and right coronary artery. He has been medically managed for the last week and now is in the operating room for coronary artery bypass grafting. After administration of a 300 units/kg dose of heparin, the activated clotting time (ACT) was 200 seconds. An additional dose of heparin is given with resultant ACT of 230 seconds. Administration of which of the following would be a MOST appropriate next step?
A. Cryoprecipitate
B. Fresh frozen plasma
C. High dose heparin
D. Hirudin

Answer 54

B. Fresh frozen plasma

Question 55

A patient becomes mildly hypotensive and has increased oxygen requirements three hours after receiving two units PRBCs; PaO2 is 100 mm Hg with an FiO2 of 40%. Which of the following is NOT an appropriate treatment option?
A. Diuretics
B. Permissive hypercapnia
C. Positive end expiratory pressure
D. Supplemental oxygen
E. Tidal volume of 5 ml/kg

Answer 55

A. Diuretics

Question 56

Which of the following would MOST LIKELY result in blood conservation in adult cardiac surgery with cardiopulmonary bypass?
A. Cessation of antifibrinolytic drugs
B. Preoperative transfusion of 2 units allogenic packed red blood cells
C. Priming the bypass pump with allogenic blood
D. Sequestration of platelets prior to bypass

Answer 56

D. Sequestration of platelets prior to bypass

Question 57

A positive direct antiglobulin test MOST LIKELY confirms which of the following transfusion reactions?
A. Acute hemolytic transfusion reaction
B. Febrile non-hemolytic
C. Graft-versus-host disease
D. Transfusion related acute lung injury

Answer 57

A. Acute hemolytic transfusion reaction

Question 58

Which of the following will cause a decrease in the P50 of oxygen?
A. Carbon monoxide
B. Acidemia
C. Hypercarbia
D. Increased temperature

Answer 58

A. Carbon monoxide

Question 59

A 36-year-old female was recently admitted for shortness of breath and found to have a pulmonary embolus. The patient reports that she had a blood clot in her calf two years ago, which was successfully treated with anti-coagulation. Laboratory work-up on the patient reveals that she has factor V Leiden disorder. Which option BEST describes the preferred treatment plan for this patient?
A. Six months of warfarin treatment with INR goal 2-3
B. One year of warfarin treatment with INR goal 2-3
C. Lifelong warfarin treatment with INR goal 2-3
D. Lifelong warfarin treatment with INR goal 3-4

Answer 59

C. Lifelong warfarin treatment with INR goal 2-3

Question 60

Which of the following BEST approximates the maximum allowable blood loss for a 70 kg, 64-year-old male? Assume a starting hematocrit of 42% and a lowest acceptable hematocrit of 30%, with estimated blood volume being 65-70 mL/kg.
A. 1,000 mL
B. 1,400 mL
C. 1,800 mL
D. 2,600 mL

Answer 60

B. 1,400 mL