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Hemostasis
It is the stoppage of bleeding from a damaged blood vessel.
IT occurs by the following mechanisms:1. Local vascular spasm
2. Formation of platelet plug
3. formation of a blood clot
4. Fibrosis of blood clot to close the hole.
5. Fibrinolysis of the blood clot to reopen blood vessel.

Mechanism of local vascular spasm


1-Myogenic mechanism :- response to trauma.
2-Nervous mechanism:-produce V.C
3- Chemical mechanism:- platelets release vasoconstrictor substances e.g serotonin

2-Platelet plug formation


Platelet adhesion
Platelet aggregation
platelet plug formation

3-Formation of a Blood Clot


It is the third mechanism of hemostasis

Steps of Blood Clotting


1. Formation of prothrombin activator. this is occur by two mechanisms extrinsic and
intrinsic .
2. Conversion of prothrombin to thrombin.
3. Conversion of fibrinogen to fibrin.
4. Fibrinolysis of the blood clot

Formation of prothrombin activator


Extrinsic mechanism
It occurs rapidly within seconds.
It begins by injury of blood vessels and surrounding tissues so it is named extrinsic
Release of tissue factor ( factor 111) or tissue thromboplastine from injured blood
vessels combine with factors V ,V11 andCa active factor X to form.( prothrombin
activator)

Intrinsic mechanism
This is more complicated than the extrinsic mechanism and it occurs more slowly.
It is so named because all factors necessary for clotting are present in the blood
itself.
Series of reactions as a result of exposure of the blood to vascular wall.
Activation of the clotting factors one after the other start from factor X11

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Thrombosis
solid mass called (thrombus) is formed from circulating blood elements mainly (platelets
and fibrin) in the C.V.S. during life
Three main factors (Virchows triad)
1- Endothelial damage (dysfunction).
2- Change in the pattern of blood flow (stasis or turbulence).
3- Changes in composition of blood ( blood coagulability).

Sites of Thrombus Formation


Venous Thrombosis:
Arterial Thrombosis
Cardiac Thrombosis
Capillaries thrombosis

Fate of Thrombi

If small dissolved via fibrinolysis

Organisation replaced by fibrous scar tissue

Recanalisation flow re-established

Calcified fibrous scar phleboliths

Detached emboli

Embolism
Occlusion of a vessel by material that has circulated though the blood
Types
1-Thromboembolism
2-Air embolism
3-Fat embolism
4-Tumour emboli
5-Amniotic fluid embolism

Pulmonary embolism
originate from thrombi of deep leg veins of the legs.
Has 3 PE :
-large embolus

- medium sized embolus -recurrent small sized emboli

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Anticoagulants

Parenteral:Heparin.
Direct thrombin inhibitor eg lepirudin.

Oral Anticoagulants:Warfarin

HEPARIN

Sulfate polysaccharide.

Not absorbed orally .

It is given by S.C or I.V. (not given I. M because it may produce muscle Haematoma)

Not cross the placenta safe in pregnancy.

Not excreted in milk safe during lactation.

Side effects:
1. Bleeding due to overdose is the most serious S.E.
2. Haematoma if given I. M.
3. Thrombocytopenia: transient reversible.
4. Osteoprosis : if used for long time.
5. Alopacia:Transient, reversible
6. Hypersensitivity reactions: rare
*if somebody has heparin toxicity,we must stop the drug and do the fresh blood
transfusion

Oral anti-coagulants: Warfarin

Absorption : Well absorbed from the GIT.

Distribution: Highly bound to the plasma proteins (>90%). Cross the placenta &
excreted in milk (contraindicated in pregnancy & lactation).

Metabolism : in the liver.

Excretion: by the kidney.

Side effects:
1.Bleeding:

is the main adverse effect e.g. haematuria, melena etc.


2. Allergy: dermatitis

3. Alopecia
4. Cross placenta: causing birth defects in early pregnamcy and foetal haemorrhage
in late pregnancy
5. Sudden withdrawal after prolonged use may lead to thrombotic episodes

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Clinical aspects of pulmonary embolism


Common signs and symptoms include:

Shortness of breath. This symptom typically appears suddenly and always gets
worse with exertion.

Chest pain. You may feel like you're having a heart attack. The pain may become
worse when you breathe deeply (pleurisy), cough, eat, bend or stoop. The pain will
get worse with exertion but won't go away when you rest.

Cough. The cough may produce bloody or blood-streaked sputum.

Other signs and symptoms that can occur with pulmonary embolism include:

Leg pain or swelling, or both, usually in the calf

Clammy or discolored skin (cyanosis)

Excessive sweating

Rapid or irregular heartbeat

Lightheadedness or dizziness

What to expect from your doctor


During the physical exam, your doctor might inspect your legs for evidence of a deep vein
clot an area that's tender, red and warm. He or she will also listen to your heart and lungs
and check your blood pressure
Blood tests
Your doctor may order a blood test for the clot-dissolving substance D dimer in your blood.
High levels may suggest an increased likelihood of blood clots, although D dimer levels may
be elevated by other factors, including recent surgery.
In addition, blood tests may be done to determine whether you have an inherited clotting
disorder.

Chest X-ray
This noninvasive test shows images of your heart and lungs on film. Although X-rays can't
diagnose pulmonary embolism and may even appear normal when pulmonary embolism
exists, they can rule out conditions that mimic the disease.
Ultrasound
A noninvasive "sonar" test known as duplex ultrasonography (sometimes called duplex scan
or compression ultrasonography) uses high-frequency sound waves to check for blood clots
in your thigh veins. In this test, your doctor uses a wand-shaped device called a transducer
to direct the sound waves to the veins being tested. These waves are then reflected back to
the transducer and translated into a moving image by a computer. The absence of the
presence of clots reduces the likelihood of DVT. If clots are present, treatment likely will be
started immediately.
CT scan
Regular CT scans take X-rays from many different angles and then combine them to form
images showing 2-D "slices" of your internal structures. In a spiral (helical) CT scan, the
scanner rotates around your body in a spiral like the stripe on a candy cane to create
3-D images. This type of CT can detect abnormalities in the arteries in your lungs with much
greater precision, and it's also much faster than are conventional CT scans. In some cases,
contrast material is given intravenously during the CT scan to outline the pulmonary
arteries.
V/Q lung scan
This test uses small amounts of radioactive material to study airflow (ventilation) and blood
flow (perfusion) in your lungs. For the first part of the test, you inhale a small amount of
radioactive material while a
camera
that's able to detect radioactive substances takes pictures of the movement of air in your
lungs. Then a small amount of radioactive material is injected into a vein in your arm, and
pictures are taken as the blood flows into the blood vessels of your lungs. Comparing the
results of the two studies helps provide a diagnosis.
Pulmonary angiogram
This test provides a clear picture of the blood flow in the arteries of your lungs. It's the most
accurate way to diagnose pulmonary embolism, but because it requires a high degree of skill
to administer and carries potentially serious risks, it's usually performed when other tests
fail to provide a definitive diagnosis.
In a pulmonary angiogram, a flexible tube (catheter) is inserted into a large vein usually in
your groin and threaded through your heart into the pulmonary arteries. A special dye is
then injected into the catheter, and X-rays are taken as the dye travels along the arteries in
your lungs.

A risk of this procedure is a temporary change in your heart rhythm. In addition, the dye
may cause kidney damage in people with decreased kidney function.
MRI
MRI scans use radio waves and a powerful magnetic field to produce detailed images of
internal structures. Because MRI is expensive, it's usually reserved for pregnant women and
people whose kidneys may be harmed by dyes used in other tests.