PHRD5015 Lecture 25 - Hemorrhage

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daynuhmay
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252559
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PHRD5015 Lecture 25 - Hemorrhage
Updated:
2013-12-11 06:28:34
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Hemorrhage
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Hemorrhage
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Hemorrhage
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  1. clotting pathway initiated by endothelial injury
    extrinsic clotting pathway
  2. low platelets
    thrombocytopenia
  3. elevated PT/INR or aPTT
    coagulopathy
  4. PT/INR (prothrombin time/international normalized ratio)
    represent extrinsic clotting time
  5. aPTT
    • activated partial thromboplastin time
    • represent intrinsic clotting time
  6. clotting cascade (4)
    • 1) vasconstriction
    • 2) thrombin activation -> fibrin clot generation
    • 3) platelet plug
    • 4) clot dissolution by plasmin
  7. step in clotting cascade at which plasmin can cause coagulopathy
    if plasmin is released during the step when thrombin activation generates the fibrin clot
  8. extrinsic system pathway (9)
    • 1) tissue factor (TF) exposed due to endothelial injury
    • 2) TF activates Factor 7 (Ca2+ & normal physiology important)
    • 3) thrombin priming
    • 4) platelet activation
    • 5) thrombin burst
    • 6) fibrinogen -> fibrin
    • 7) fibrin sticks to injury site
    • 8) platelets adhere to fibring
    • 9) plasmin released to break down clot
  9. factors contributing to massive bleeding (8)
    • 1) anti-coag's/plt inhibition
    • 2) age
    • 3) trauma type
    • 4) invasiveness of surgery
    • 5) thrombocytopenia
    • 6) coagulopathy
    • 7) liver failure
    • 8) disseminated intravascular coagulopathy
  10. Lethal Triad
    • hypothermia
    • acidosis
    • coagulopathy
  11. natural anticoagulant
    Protein C
  12. reduced thrombomodulin ->
    increased free thrombin -> clotting -> inhibition of clot breakdown
  13. DIC
    • disseminated intravascular coagulopathy
    • inflammatory response -> thrombomodulin consumption/depletion -> increased thrombin as pro-coagulant
  14. Hb value goal when pt is bleeding out
    7g/dL
  15. Hb value in early goal directed sepsis treatment
    10g/dL
  16. how to begin fluid rescuscitation
    give pt 2L NS
  17. what to give pt that is bleeding out
    fibrinogen
  18. what does preservative citrate bind to in blood?
    calcium
  19. used early in massive bleeding, when INR or aPTT is prolonged
    fresh frozen plasma (FFP) or prothrombin complex concentrates (PCC)
  20. given for low fibrinogen
    cryoprecipitate
  21. given during refractory hemorrhage
    • rFVIIa & rFVIIIa (when VIIa stops working)
    • *pro-coagulants
  22. V2 agonist that makes platelets stick together; good when pt is on a platelet inhibiting drug
    DDAVP
  23. prevent clots from breaking down (general)
    anti-fibrinolytics
  24. Factor 7 vs Factor 8
    • 7 works at activated plt and starts thrombin burst
    • 8 works at fibrinogen (last clotting factor)
  25. tx to raise pH
    sodium bicarbonate IV
  26. tx for resuscitation
    NS, RBC
  27. tx for thrombin burst
    • rFVIIa 
    • rFVIIIa

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