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BLEEDING DISORDERS

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Title: BLEEDING DISORDERS


1
BLEEDING DISORDERS
  • LCDR ART GEORGE

2
HEMOSTASIS
1. VASCULAR PHASE 2. PLATELET PHASE 3.
COAGULATION PHASE 4. FIBRINOLYTIC PHASE
3
VASCULAR PHASE
  • WHEN A BLOOD VESSEL IS DAMAGED, VASOCONSTRICTION
    RESULTS.

4
HEMOSTASIS
1. VASCULAR PHASE 2. PLATELET PHASE 3.
COAGULATION PHASE 4. FIBRINOLYTIC PHASE
5
PLATELET PHASE
  • PLATELETS ADHERE TO THE DAMAGED SURFACE AND FORM
    A TEMPORARY PLUG.

6
HEMOSTASIS
1. VASCULAR PHASE 2. PLATELET PHASE 3.
COAGULATION PHASE 4. FIBRINOLYTIC PHASE
7
COAGULATION PHASE
  • THROUGH TWO SEPARATE PATHWAYS THE CONVERSION OF
    FIBRINOGEN TO FIBRIN IS COMPLETE.

8
HEMOSTASIS
1. VASCULAR PHASE 2. PLATELET PHASE 3.
COAGULATION PHASE 4. FIBRINOLYTIC PHASE
9
FIBRINOLYTIC PHASE
  • ANTICLOTTING MECHANISMS ARE ACTIVATED TO ALLOW
    CLOT DISINTEGRATION AND REPAIR OF THE DAMAGED
    VESSEL.

10
HEMOSTASIS
  • DEPENDENT UPON
  • Vessel Wall Integrity
  • Adequate Numbers of Platelets
  • Proper Functioning Platelets
  • Adequate Levels of Clotting Factors
  • Proper Function of Fibrinolytic Pathway

11
THE CLOTTING MECHANISM
INTRINSIC
EXTRINSIC
Tissue Thromboplastin
Collagen
XII
XI
VII
IX
VIII
X
FIBRINOGEN
V
(I)
PROTHROMBIN THROMBIN
(II)
(III)
FIBRIN
12
LABORATORY EVALUATION
  • PLATELET COUNT
  • BLEEDING TIME (BT)
  • PROTHROMBIN TIME (PT)
  • PARTIAL THROMBOPLASTIN TIME (PTT)
  • THROMBIN TIME (TT)

13
PLATELET COUNT
  • NORMAL 100,000 - 400,000 CELLS/MM3
  • lt 100,000
    Thrombocytopenia
  • 50,000 - 100,000 Mild Thrombocytopenia
  • lt 50,000 Sev Thrombocytopenia

14
BLEEDING TIME
  • PROVIDES ASSESSMENT OF PLATELET COUNT AND
    FUNCTION
  • NORMAL VALUE
  • 2-8 MINUTES

15
PROTHROMBIN TIME
  • Measures Effectiveness of the Extrinsic Pathway
  • Mnemonic - PET
  • NORMAL VALUE
  • 10-15 SECS

16
PARTIAL THROMBOPLASTIN TIME
  • Measures Effectiveness of the Intrinsic
  • Pathway
  • Mnemonic - PITT

NORMAL VALUE 25-40 SECS
17
THROMBIN TIME
  • Time for Thrombin To Convert
  • Fibrinogen Fibrin
  • A Measure of Fibrinolytic Pathway

NORMAL VALUE 9-13 SECS
18
So What Causes Bleeding Disorders?
  • VESSEL DEFECTS
  • PLATELET DISORDERS
  • FACTOR DEFICIENCIES
  • OTHER DISORDERS

?
?
19
VESSEL DEFECTS
  • VITAMIN C DEFICIENCY
  • BACTERIAL VIRAL INFECTIONS
  • ACQUIRED

20
So What Causes Bleeding Disorders?
  • VESSEL DEFECTS
  • PLATELET DISORDERS
  • FACTOR DEFICIENCIES
  • OTHER DISORDERS

?
?
21
PLATELET DISORDERS
  • THROMBOCYTOPENIA
  • THROMBOCYTOPATHY

22
THROMBOCYTOPENIA
INADEQUATE NUMBER OF PLATELETS
23
THROMBOCYTOPATHY
  • ADEQUATE NUMBER BUT ABNORMAL FUNCTION

24
THROMBOCYTOPENIA
  • DRUG INDUCED
  • BONE MARROW FAILURE
  • HYPERSPLENISM
  • OTHER CAUSES

25
THROMBOCYTOPENIA
  • DRUG INDUCED

Alcohol
Thiazide Diuretics
26
THROMBOCYTOPENIA
  • DRUG INDUCED
  • BONE MARROW FAILURE
  • HYPERSPLENISM
  • OTHER CAUSES

27
THROMBOCYTOPENIA
  • BONE MARROW FAILURE
  • Viral Infections
  • Nutritional Deficiencies
  • Chemotherapy Radiation Therapy
  • Infiltration of Abnormal Cells
  • Aplastic Anemia
  • Leukemia
  • Metastatic Cancer

28
THROMBOCYTOPENIA
  • DRUG INDUCED
  • BONE MARROW FAILURE
  • HYPERSPLENISM
  • OTHER CAUSES

29
THROMBOCYTOPENIA
  • HYPERSPLENISM
  • Increase in Size Leads to Destruction of
    Platelets
  • Associated with Portal Hypertension Seen in
    Patients with Cirrhosis

30
THROMBOCYTOPENIA
  • DRUG INDUCED
  • BONE MARROW FAILURE
  • HYPERSPLENISM
  • OTHER CAUSES

31
THROMBOCYTOPENIA
  • OTHER CAUSES
  • Lymphoma
  • HIV Virus
  • Idiopathic Thrombocytopenia Purpura (ITP)

32
THROMBOCYTOPATHY
  • UREMIA
  • INHERITED DISORDERS
  • MYELOPROLIFERATIVE DISORDERS
  • DRUG INDUCED

33
THROMBOCYTOPATHY
  • DRUG INDUCED

ASPIRIN
IRREVERSIBLY BINDS TO THE PLATELET FOR ITS
ENTIRE LIFESPAN (7-10 DAYS)
34
THROMBOCYTOPATHY
  • DRUG INDUCED

NSAIDS
REVERSIBLY BINDS TO THE PLATELET FOR A LIMITED
TIME PERIOD (APPROX 6 HOURS)
35
So What Causes Bleeding Disorders?
  • VESSEL DEFECTS
  • PLATELET DISORDERS
  • FACTOR DEFICIENCIES
  • OTHER DISORDERS

?
?
36
FACTOR DEFICIENCIES (CONGENITAL)
  • HEMOPHILIA A
  • HEMOPHILIA B
  • VON WILLEBRANDS DISEASE

37
FACTOR DEFICIENCIES
  • HEMOPHILIA A (Classic Hemophilia)
  • 80-85 of all Hemophiliacs
  • Deficiency of Factor VIII
  • Lab Results - Prolonged PTT
  • HEMOPHILIA B (Christmas Disease)
  • 10-15 of all Hemophiliacs
  • Deficiency of Factor IX
  • Lab Test - Prolonged PTT

38
FACTOR DEFICIENCIES
  • VON WILLEBRANDS DISEASE
  • Deficiency of VWF amount of Factor VIII
  • Lab Results - Prolonged BT, PTT

39
So What Causes Bleeding Disorders?
  • VESSEL DEFECTS
  • PLATELET DISORDERS
  • FACTOR DEFICIENCIES
  • OTHER DISORDERS

?
?
40
OTHER DISORDERS (ACQUIRED)
  • ORAL ANTICOAGULANTS
  • COUMARIN
  • HEPARIN
  • LIVER DISEASE
  • MALABSORPTION
  • BROAD-SPECTRUM ANTIBIOTICS

41
OTHER DISORDERS
  • ORAL ANTICOAGULANTS
  • Coumarin Prevents Thromboembolic Events
  • is a Vit K Antagonist. Monitored by PT times.
  • Heparin Therapy is Monitored by PTT times.

42
OTHER DISORDERS
  • MALABSORPTION
  • Various Intestinal Diseases Will Interfere w/
    Bile Acid Metabolism.
  • Bile Acids are Required for Vit K Absorption so
    You Will See a Deficiency in Vit K Dependent
    Coagulation Factors (II,VII,IX,X).

43
OTHER DISORDERS
  • LIVER DISEASE
  • Jaundice Results in Malabsorption of Vit K.
  • Liver Disease can Result in Reduced
    Production of Coagulation Factors
    (I,II,V,VII,IX,X).

44
OTHER DISORDERS
  • BROAD-SPECTRUM ANTIBIOTICS
  • Change in Intestinal Flora which Might
    Decrease Vitamin K Production.
  • Vitamin K is Necessary for the Liver to Produce
    Coagulation Factors II,VII,IX,X.

45
DENTAL EVALUATION
  • GOOD THOROUGH MEDICAL HISTORY
  • A PHYSICAL EXAMINATION
  • SCREENING CLINICAL LAB TESTS
  • EXCESSIVE BLEEDING FOLLOWING SURGICAL PROCEDURE

46
GOOD THOROUGH HISTORY
  • Family HX
  • Personal HX
  • Medications
  • Past Present Illness
  • Spontaneous Bleeding

47
REVIEW PATIENTS MEDS
  • FIVE DRUGS THAT INTERFERE WITH HEMOSTASIS
  • ASPIRIN
  • ANTICOAGULANTS
  • ANTIBIOTICS
  • ALCOHOL
  • ANTICANCER

48
ORAL MANIFESTATIONS
  • Petechiae Ecchymosis
  • Gingival Hyperplasia
  • Spontaneous Gingival Bleeding
  • Ulceration of Oral Mucosa
  • Lymphadenopathy

49
LEUKEMIA
50
DENTAL PATIENTS
  • LOW RISK
  • Patients with No Hx of Bleeding Disorders
  • Normal Laboratory Results
  • MODERATE RISK
  • Patients on Chronic Oral Anticoagulant

    Therapy. PT is 1.5 - 2 Times Control Range
  • Patients on Chronic Aspirin Therapy

51
DENTAL PATIENTS
  • HIGH RISK
  • Patients with Known Bleeding Disorders
  • Patients without Known Bleeding Disorders Who
    Have Abnormal Laboratory Results

52
DENTAL MANAGEMENT
  • LOW RISK PATIENTS
  • Normal Protocol
  • MODERATE RISK PATIENTS
  • Anticoagulants - Consult Physician
  • Aspirin Therapy - BT, Consult Physician

53
DENTAL MANAGEMENT
  • HIGH RISK PATIENTS
  • Close Coordination with Physician
  • Hospitalization (Platelet Transfusion)
  • (Factor Replacement)
  • (Vit K Therapy)
  • (Dialysis)

54
ANY QUESTIONS?
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