coagulation cme 2007
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Coagulation
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Blood clot
• Platelets (150 - 400K)– Activated by collagen, thrombin, etc.
– Release platelet and coagulation factors
• Insoluble fibrin molecules– Prothrombin is converted to thrombin
– Thrombin binds soluble fibrin into insoluble mesh
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QuickTime™ and aTIFF (Uncompressed) decompressor
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Controlling Clotting
• AntithrombinIII: inhibits the formation of thrombin by binding to and inactivating:•prothrombin•factor 9•factor 10
• Heparin is a mixture of polysaccharides that bind to antithrombin III & enhance inhibition of thrombin synthesis.– prothombin (Factor II) to Thrombin
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Vitamin K
• Vitamin K is required (as a cofactor) for the body to make four of the blood's coagulation (clotting) factors: particularly prothrombin and also factors VII, IX, and X
• K was for Koagulation (Danish for coagulation)
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Coumadin (Warfarin)
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Prothrombin time, PTCoumadin/warfarin
• PT reflects the depression of vitamin K dependent Factors VII, X and II.
• A system of standardizing the PT International Normalized Ratio (INR) provides a common basis for communication of PT results and interpretations of therapeutic ranges– 1 is baseline (normal), 2-3.5 is therapeutic
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Activated Partial Thromboplastin Time
Heparin inactivates factor II, prothrombin• Evaluates function of
– Intrinsic (XII, XI, IX, VII)– Common(V, X, II, I)
• Used to evaluate heparin therapy• Also used as first step evaluation of coagulopathy.
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Standard heparin (Unfractionated)
• Variety of molecule lengths.
• Smaller molecules much more effective.
• Must test, PTT, for therapeutic level.
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Low molecular weight heparinLovenox,
• More consistent dosing
• No need to test PTT
• SQ administration, twice daily
• Costs more
• Lower rates of HITQuickTime™ and a
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Heparin induced thrombocytopenia
• Decrease in platelet count• Increased risk of arterial and venous thrombosis• DVT risk is most common complication
• Type I, 10 to 20% of heparinized patients, PLTs fall 50% but rarely under 100K
• Type II rare but serious autoimmune disorder.
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Thrombolytics
Tissue plasminogen activator (TPA)
Dissolves existing blood clots
Therapeutic for Ischemic heart disease and strokes
Risk of bleeding
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What does this have to do with EMS?
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• Recognize symptoms of stroke
• Transport to Appropriate facility
• Consider effect of Anticoagulant therapy with patients with falls and head trauma
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• AIRWAY