Week 2 Flashcards
What are the 4 steps of the normal haemostatic response?
Formation of platelet plug (primary haemostasis)
Formation of fibrin clot (secondary haemostasis)
Fibrinolysis
Anticoagulation defences
What large precursor cell do platelets arise from?
Megakaryocytes
Do platelets have a nucleus?
How long is a platelet lifespan?
They are anucleate
Lifespan is 7-10 days
How does endothelial damage and subsequent exposure of collagen recruit platelets to the site of injury?
Exposure of collagen causes release of von Willebrand Factor and other proteins which causes platelet adhesion
Once adhered, platelets secrete various chemicals which leads to further platelet aggregation
Why might a platelet plug fail to form?
Vascular reasons - elderly patients/vitamin C deficiency (e.g. alcoholics)
Platelets either reduced in number (thrombocytopoenia), most commonly caused deliberately by iatrogenic intervention e.g. warfarin following MI, or reduced platelet function
Errors with von Willebrand Factor
What might some of the signs be in the event of failure of platelet plug formation?
Spontaneous bruising and purpura (most common, esp. in elderly)
Bleeding from mucosal sites (nose, GI, conjunctival, menorrhagia)
Retinal haemorrhages
Intracranial haemorrhage (rare, more severe)
What screening test is performed to assess primary haemostasis?
Reminder - primary haemostasis is platelet plug formation
Only one test - platelet count!
What is secondary haemostasis?
Formation of the fibrin clot
What coagulation factors are responsible for the initiation of fibrin clot formation?
Tissue Factor
Factor VIIa
What coagulation factors are required for the propagation of prothrombin (Factor II) to thrombin (Factor IIa)?
Factor V
Factor Xa
What coagulation factors are required for the amplification of thrombin in the formation of the fibrin clot?
Factor VIII
Factor IXa
Which coagulation factors are absent in the following forms of haemophilia?
- Haemophilia A
- Haemophilia B
- Haemophilia C
Haemophilia A - Factor VIII
Haemophilia B - Factor IX
Haemophilia C - Factor XI
What is the usual cause of a deficiency in a SINGLE clotting factor? Examples?
What is the usual cause of a deficiency of MULTIPLE clotting factors? Examples?
Single - usually hereditary e.g. Haemophilia
Multiple - usually acquired e.g. liver cirrhosis, Disseminated Intravascular Coagulopathy (e.g. in the case of major trauma, clotting factors are used up)
Describe the process of fibrinolysis
What marker is an indicator of the degree of fibrinolysis?
Plasminogen is converted to Plasmin in the presence of Tissue Plasminogen Activator (tPA)
Plasmin then breaks Fibrin down into Fibrin Degradation Products (FDPs). This can be measured clinically and is known as D-Dimer
What screening tests are there to assess fibrin clot formation? What exactly do they measure?
Prothrombin Time - measures Tissue Factor and Factor VIIa
Activated Partial Thromboplastin Time - measures Factor VIII and Factor IXa
Patient comes to you with some symptoms that could suggest a bleeding disorder - what questions do you ask?
History - bleeding/bruising (what is normal?), duration (has it been life-long?), any previous surgeries or dental extractions?
Drug history - especially if blood thinners
Family History - could be congenital
Social history - do they smoke or drink? Think about malignancies and liver pathology
What are the body’s naturally occuring anticoagulants and how do they work?
Serine protease inhibitors e.g. antithrombin III - switches off clotting process via thrombin inactivation, as well as Factors V/Xa, Tissue Factor and Factor VIIa, and Factors VIII/IXa (clue is in the name!)
Protein C and Protein S - thrombin binds to thrombomodulin which in turn activates PC and PS to swtich off the clotting process via Factors V/Xa and Factors VIII/IXa (thrombin regulates its own clotting!)
What is the name of the hereditary condition that results from a deficiency of naturally occuring anticoagulants?
What presentation does this condition have an increased tendency for?
Thrombophilia
Increased tendency for patients to present with Deep Vein Thrombosis/Pulmonary embolism
What are the five signs that could determine if a patient is in shock (described as “windows” in the lecture)?
Skin changes - i.e. fixed mottling
Brain changes - confusion, as seen in a drop in GCS
Kidney changes - low urine output
Changes seen on Sidestream Dark Field Microscopy
Raised Lactate (used to confirm)
What are the 4 separate phsyiological mechanisms of shock?
- Cardiogenic
- Obstructive
- Hypovolaemic
- Distributive
What are the 3 components of Virchow’s Triad?
Hypercoagulability
Stasis
Endothelial injury
A MAP above what is required to adequately perfuse organs?
Above 50-60 mmHg
Bleeding disorders can arise from each part of the normal haemostatic system (primary and secondary haemostasis, fibrinolysis and anticoagulant defences). What might cause dysfunction of primary haemostasis?
Primary haemostasis = formation of the platelet plug
Vascular causes
- increasing age
- steroids
- autoimmune causes (e.g. vasculitis such as Henoch-Schonlein Purpura)
- vitamin C deficiency (required for collagen)
- inherited collagen disorders (e.g. Marfan’s)
Platelet causes
- reduced number (thrombocytopenia - most common cause of primary haemostasis failure)
- increased destruction
- reduced production
- reduced function
von Willebrand Factor problems
- von Willebrand Disease
Where might you see purpura in a patient with HSP (autoimmune vasculitis)?
Lower limbs
Chest
Mouth
Retina
What are some of the causes of peripheral platelet destruction (resulting in thrombocytopenia)?
Which of these is the most common cause?
Disseminated Intravascular Coagulopathy (DIC)
Autoimmune - immune thrombocytopenic purpura (ITP) - isolated low platelet count with normal bone marrow and the absence of other causes of thrombocytopenia. Causes characteristic purpuric rash and increased tendency to bleed
Hypersplenism i.e. as a result of liver disease causing build up (portal hypertension) and leaving the blood in the spleen
What common autosomal dominant hereditary condition might result in reduced platelet function?
What clotting factor might also be affected?
von Willebrand Disease (vWF deficiency)
vWF also carries around Factor VIII, so when levels of vWF become very low factor VIII may become deficient
Thrombocytopenia is the most common cause of failure of primary haemostasis - what can cause thrombocytopenia?
Thrombocytopenia = reduced platelet numbers
Caused by either marrow failure or peripheral destruction (DIC, ITP, hypersplenism secondary to liver disease)
What clotting factors are involved in the extrinsic pathway?
Which screening test measures the function of this pathway?
Tissue Factor and Factor VII and VIIa
Go on to activate Factor X to Xa and Factor V
Prothrombin Time measures the effectiveness of this pathway
What clotting factors are involved in the intrinsic pathway?
Which screening test measures the function of this pathway?
Factor XII activates to XIIa, which activates Factor XI to XIa
Factor XIa activates Factor IX which with it’s co-factor Factor VIIIa (forming the tenase complex) go on to activate Factor X
VIII/IXa (tenase complex) is measured by the activated Partial Thromboplastin Time (aPTT)
The extrinsic/intrinsic pathway is responsible for initiating the clotting cascade
The extrinsic/intrinsic pathway is then responsible for amplifying the response
Extrinsic = initiation
Intrinsic = amplification
Why might the fibrin clot fail to form (secondary haemostasis)?
Clotting Factor Deficiency