Onc.1 Thrombosis/thrombocytopenia

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Objectives

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Front 2

Review: primary hemostasis, 2ndary hemostasis, and resolution

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Front 3

review: 3 steps of platelet plug formation

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adhesion: platelets stick to injured endothelium

aggregation: platelets attract each other

activation: procoagulatn stimulation of clotting cascade

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review : disorders in 1º vs. 2º hemostasis and how they present

1. pattern of bleeding

2. site

3. onset

4. example conditions

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Front 5

Screening for bleeding disorder? 2 components

Back 5

1. take the history

2. simple lab tests: CBC/diff, PBS, INR, PTT

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questions to ask in the bleeding history.. 8

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+ PMHx (liver, renal disease, CT disease)

+ Meds (ASA, anticoags, NSAIDS)

+ FMHx bleeding problems

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Lab tests to screen for bleeding risk

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Front 8

Note: when is no further testing required

when is further testing required

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How is thrombocytopenia defined?

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<140x10^9 cells at the U of A

NOT a diagnosis. IS a lab value that must be explained.

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Thrombocytopenia: typical bleeding pattern

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Front 11

note: threshold for minor spontaenous bleeds?

threshold for life threatening bleed?

wrt platelet counts

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sx may not be evident until count drops below 30 or even 20

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Can approach low platelets by pathologic category: dec. production, inc. destruction, sequestration

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Front 13

dec. production: 5 to consider

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Front 14

increased PLT destruction: immune mediated vs. consumptive

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PLT sequestration: 3

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Front 16

The 3 letter platelet conditions of thrombocytopenia. there are 4. 3 are emergencies..

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pathophys of ITP

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ITP in Kids:

1. age group

2. natural history

3. potential platelet counts

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Front 19

Rx of ITP in kids

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IVIG:flood system with ab’s, and it’s not as easy from immunesystem to attack platelets. Rituximab:wipes out b lymphs. This resets immune system andhopefully when it grows back, it is not autoimmune

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ITP IN ADULTS

1. M:F

2. bleeding risk

3. platelet counts

4. natural history

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Front 21

ITP in adults: Tx

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ITP is a diagnosis of exclusion

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rule out the bad stuff...

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the 3 letter platelet emergencies.. 3

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note: DIC is a syndrome 2ndary to severe systemic illness

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k

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pathophys of DIC

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Clinical Features of DIC

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1. Low PLT count on CBC with occasional red cell fragments

2. bleeding!

3. thrombosis: digital infarcts, stroke/neuro/end organ damage

4. other labs: anemia, prolonged PT, PTT, depleted clotting factors

5. low fibrinogen

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lab findings in DIC 5

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1. anemic

2. prolonged PT, PTT

3. depleted clotting factors

4. low fibrinogen

5. low platelet count

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Therapy of DIC?

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1. treat underlying disease

2. replace clotting factors (plasma) and fibrinogen (cryoprecipitate) if bleeding

3. low dose heparin if thrombosis dominates

Front 29

two types of MAHA (microangiopathic hemolytic anemia)

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TTP: thrombotic thrombocytopenic purpura

HUS: hemolytic uremic syndrome

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TTP and HUS: clinnical features? 2

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Front 31

what is required to diagnose MAHA? 2

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1. low platelets with hemolytic anemia

2. red cell fragmentation on blood film

if you have these 2, the diagnosis is made

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Classical pentad of TTP?

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only need first 2 for dx

1. hemolytic anemia

2. red cell fragmentation

----

3. Fever

4. renal failure

5. neuro symptoms

THE ABSENCE OF FULL PENTAD DOES NOT MAKE TTP LESS LIKELY

Front 33

How to diff't HUS from TTP on basis of

age

neuro manifestations

renal manifestations

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Front 34

pathophys of TTP/HUS

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depletion of vWF cleaving metalloprotease (ADAMTS13) is responsible for the syndrome

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diagram: pathophys TTP/HUS

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Front 36

mech of red cell shearing in MAHA

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Front 37

normal vs. TTP blood film

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Front 38

HUS;

1. etiology

2. prodrome..

3. Rx

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Front 39

Causes of TTP

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d

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TTP:

1. definitive care

2. supportive care to do while arranging transfer?

3. Other Treatments

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Front 41

HIT:

1. clinical syndrome?

2. manifestations

3. when to consider

4. how to monitor...

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Front 42

HIT pathophysiology

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Front 43

Who gets HIT/HIT antibodies? 4

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Front 44

4T score gives a pretest probability for HIT. DNM

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Diagnosis of HIT?

what rules in HIT? what rules out?

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Front 46

functional assays in HIT ..

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Rx HIT:

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1. stop heparin

2. anticoagulate with alternate drug

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Hx to take in thrombocytopenia

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PE in thrombocytopenia

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investigations in thrombocytopenia

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Front 51

LOW PLT: what do we do if HB is low?

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MUST LOOK FOR HEMOLYSIS: (retic count, LDH, Bilirubin, Haptoglobin)

consider TTP...

Front 52

Investigation of low PLT.. coag tests? HIT suspected? Serologic tests?

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Front 53

features that separate ITP, DIC, and TTP/HUS

1. PLT levels

2. PT/PTT

3. Fibrinogen

4. red cell fragments

5. patient Gen. appearance...

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Front 54

Objectives: VTE

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Front 55

why does the Superficial femoral vein have the stupidest name in the world

Back 55

because it is actually a DEEP vein

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review: virchow's triad

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1. stasis

2. vessel wall injury

3. hypercoagulability

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example causes of venous stasis 5

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example causes of hypercoagulability 6

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causes of vascular injury

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Front 60

VTE risk factors

explain importance of additive risk factors, and age

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Front 61

VTE: importance of provoked vs. unprovoked

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Front 62

where do blood clots form?

note: weird clot sites may require workup..

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relationship between DVT and PE...

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Front 64

Dx of VTE: clinical findings are neither sensitive nor specific ..

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Sx DVT/PE

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Modified wells 7

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Front 68

review: D dimer is sensitive but not specific for VTE

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Imaging studies in VTE

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Extra imaging pointers

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Clotting cascade review

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How to treat DVT? (drug, dosages, etc)

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LMWH:

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Coumadin: dosing, monitoring, target INR, timing of onset

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Note: INR reflects the dose of coumadin given ___ hr earlier

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48 hours

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example coumadin dosing schedule

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how to manage bleeding on warfarin?

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minimum duration of anticoagulation?

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thrombophilia workup//

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note: hypercoagulable workup should NOT be routinely ordered on all patients with clot

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d

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mechanisms of increased clot risk in cancer

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VTE treatment in cancer...

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