MECHANISMS OF COAGULATION AND FIBRINOLYSIS

Blood extravasation is normally controlled or prevented by the delicate balance among at least five
components and their biochemical reactions:

1.)

2.)

3.)

4.)

5.)

Blood is prevented from leaving the vascular system by the lining of endothelial cells in the blood
vessels, this endothelial lining can be disrupted by:

1.)

2.)

3.)

HEMOSTASIS OVERVIEW

PRIMARY HEMOSTASIS SECONDARY HEMOSTASIS

ACTIVATION
COMPONENTS
END PRODUCTS
LABORATORY TESTS

COAGULATION NOMENCLATURE

FACTOR MNEMONICS PREFERRED NAME

I F
II P
III T
IV C
V L
VII S
VIII A
IX C
X S
XI P
XII H
XIII F
 FIBRINOGEN GROUP PROTHROMBIN GROUP CONTACT GROUP

FIBRINOGEN PROTHROMBIN CONTACT

VITAMIN K
DEPENDENT FOR
SYNTHESIS?
ADSORBED BY
BARIUM SULFATE OR
ALUMINUM
HYDROXIDE AND
OTHER SALTS?
CONSUMED IN
COAGULATION?
ACUTE PHASE
REACTANTS?
PRODUCTION
REDUCED BY ORAL
ANTICOAGULANTS?

THE FIBRINOLYTIC SYSTEM

ACTIVATION OF PLASMIN TO PLASMINOGEN

Fibrinolysis is dependent on the enzyme ____________, which normally is not present in the blood in an
active form. Plasmin, a __________________ Iike many of the coagulation factors, can digest or destroy
_____________, ________________, and ____________________. Plasmin also promotes coagulation
and activates the __________ and _______________________.

A zymogen known as _______________, which normally is present in plasma, is converted to _________

by the action of specific enzymes called _________________________. Plasminogen is a single-chain
_______________ that is synthesized in the _________ and has a molecular weight of ______________.
It is stored and transported in ____________. Increased concentrations are found in association with
_________________.

Activation of plasminogen to plasmin may occur because of substances normally present in the
___________. Such activation is referred to as ___________________. Extrinsic activation occurs
through substances that enter the plasma from an __________________.
 MULTIPLE ROLES OF PLASMIN IN HEMOSTASIS

PLASMIN’S ROLE COMMENTS

Cleaves fibrin and fibrinogen to fibrin (ogen)
degradation products X, Y, D, E
Factor XII → XIIa is amplified indirectly by plasmin
Destroys factor VIII and V
Fibrin (ogen) degradation products interfere with
thrombin influence on fibrinogen
Enhances conversion of prekallikrein to kallikrein
and subsequently of kininogen to kinin
Cleaves C3 into fragments C3a and C3b and
activates C1, the first component in the
complement system.

NATURALLY OCCURING INHIBITORS OF FIBRINOLYSIS

Alpha-2-Antiplasmin

•
•
•

Alpha-2-Macroglobulin

•
•
•

Alpha-1-Antitrypsin

•
•
•

Other Fibrinolytic Inhibitors

________________________ also functions to inhibit __________________ by inhibiting

______________ and _________________. The _____________________ also inhibits plasmin.
 BLOOD LABORATORY: HEMOSTASIS

When a body tissue is injured and begins to bleed, it initiates a sequence of clotting factor activities
– the coagulation cascade – leading to the information of a blood clot. This cascade is compromised
of three pathways: ________________, __________________ and _____________________.

Two laboratory tests are used commonly to evaluate coagulation disorders:

________________________ which measures the integrity of the extrinsic system as well as factors
common to both systems and _________________________ which measures the integrity of the
intrinsic system and the common components.

BLOOD CLOT FORMATION

Clotting is a function of plasma. It depends upon the orderly interaction of a group

of __________________ (which are sequentially activated following vascular injury) with
some ________________ (from either damaged tissue or platelets) and some ___________. The
final stages include the formation of _______________, which then converts:

soluble plasma protein fibrinogen insoluble fibrin.

Another factor converts the fibrin into a cross-linked polymer which stabilizes the platelet plug and
traps RBCs in the meshwork to form the actual blood clot. Depending on the type of vascular
damage or abnormality, clotting can be initiated and proceed according to two different cascading
pathways: the _____________ (initiated by contact with and abnormal/foreign surface) or
the ________________ (initiated by exposure to tissue factors). Note that:

• the two pathways converge, so that the final steps are common to the two schemes
• although clotting can be initiated via either the more rapid (15-20 seconds) extrinsic scheme
or the slower (2-6 minutes) intrinsic scheme.
• the division into two pathways is only an artifact of ____________ testing: the two
pathways interconnect at several levels. ______________, both pathways must be activated
for effective hemostasis.
• both coagulation pathways, by a series of feedback mechanisms, control their own activity
(e.g. traces of thrombin enhance the activity of earlier factors in the scheme).

Note also that, in addition to the coagulation-promoting factors, there are also substances in blood
which inhibit coagulation (e.g., an anti-thrombin factor which inactivates thrombin). Whether or
not blood coagulates depends on the balance that exists between the two groups of factors (pro-
coagulants and anti-coagulants).

PROTHROMBIN TIME (PT) TEST

The PT test is used to monitor patients taking certain medications as well as to help diagnose
______________________.
A sample of the patient's blood is obtained by _________________. The blood is decalcified (by
collecting it into a tube with oxalate or citrate ions) to prevent the clotting process from starting before
the test. The blood cells are separated from the liquid part of blood (plasma) by centrifugation. The PT
test is performed by adding the patient's plasma to some source of Tissue Factor (e.g.: a protein,
thromboplastin, from homogenized brain tissue) that converts prothrombin to thrombin. The mixture is
then kept in a warm water bath at _________ for____________. Calcium chloride (excess quantities of
ionized calcium) is added to the mixture in order to counteract the sodium citrate and allow clotting to
start. The test is timed from the addition of the calcium chloride until the plasma clots. This time is
called the _________________.

The prothrombin test specifically evaluates the presence of factors _____, _____, and _____,
____________, and_____________. A prothrombin time within the _________________ range
(depends on the source of thromboplastin used) indicates that the patient has normal amounts of the
above clotting factors.

A ________________________ indicates a deficiency in any of factors VII, X, V, prothrombin, or

fibrinogen. It may mean that the patient has a vitamin K deficiency (vitamin K is a co-factor in the
synthesis of functional factors II (prothrombin), VII, IX and X) or a liver disease (the liver is the site of
synthesis of the plasma protein factors). The prothrombin time of patients receiving a vitamin K-
competing coumarin drug such as ____________ (anticoagulation therapy used in deep venous
thrombophlebitis) will also be prolonged, usually in the range of one and one half to two times the
normal PT time.
ACTIVATED PARTIAL THROMBOPLASTIN TIME (APTT) TEST

The ____________________________ (APTT) is a test performed to investigate bleeding disorders and

to monitor patients taking an anticlotting drug such as ____________ which inhibits factors X and
thrombin, while activating anti-thrombin.

The APTT test uses blood which is decalcified to prevent clotting before the test begins. The plasma is
separated by centrifugation. (Ionized) Calcium and activating substances are added to the plasma to start
the intrinsic pathway of the coagulation cascade. The substances are: __________ (hydrated aluminum
silicate) and ___________. Kaolin serves to activate the contact-dependent Factor XII, and cephalin
substitutes for platelet phospholipids. The partial thromboplastin time is the time it takes for a clot to form,
measured in seconds. Normally, the sample will clot in ___________.

APTT measures the integrity of the intrinsic system (Factors _____, ______, ______, ______) and
common clotting pathways.

Increased levels in a person with a bleeding disorder indicate a clotting factor may be missing or
defective. At this point, further investigation is needed and warrants the use of sensitive assays for
specific coagulation factors. _____________ decreases production of factors, increasing the APTT.
 CLOTTING TIME
Use to:

▪ To diagnose _______________________
▪ Time taken for blood sample to __________ or ___________ in vitro

LEE AND WHITE METHOD

Requirements:

➢ ______________ size tubes

➢ Water bath with ________________

Equipment for phlebotomy:

• S
• S
• S
• G

Procedure:

❖ ____________________ is the time from the moment of puncture to the average time at which
the tubes can be tilted to an angle more than _______ without spilling the blood.
❖ The average time taken for clotting in both tubes - ____________________
❖ Normal range: ________ minutes

BLEEDING TIME
Tool to test:

▪ _____________________ formation
▪ _________________ integrity
✓ Ordered on patient scheduled for _____________

Dependent upon:

➢ Efficiency of tissue fluid in accelerating _______________________

➢ On ______________________
➢ Number of __________________ present
➢ Ability to form a _____________________
DUKE’S METHOD

Requirements:

➢ Sterile, disposable ___________________

➢ __________________
➢ No. 1 circular ___________________
➢ Spirit and ____________________
➢ ____________

Procedure:

❖ Patient is pricked with a lancet preferably on the ___________or ____________ after having
been swabbed with alcohol. Let the alcohol dry.
❖ Prick the fingertip, the prick should be about ___________ deep. At the same time, start the
stopwatch. Wipe the blood every ______________ with the filter paper take in care to wipe it
from the side and not directly on the puncture site.
❖ The test ceases when __________ ceases.
❖ Normal range: _______ minutes

Disadvantages:

▪ Least ________________
▪ Least precision and _____________

Precautions:

▪ ________________ pricker is prescribed

▪ _____________ of blood should not be avoided
▪ ________ is noted properly

IVY METHOD

Use to see:

• ______________ to stop bleeding

• _____________________ after puncture

Drugs causing falsely abnormal value:

✓ _____________
✓ Aspirin containing compounds
✓ Blood thinners like ___________ or _____________

Requirements:

➢ Sterile disposal _________

 ➢ ______________
➢ No.1 circular _________________
➢ _________ and cotton swabs
➢ _______________________

Procedure:

❖ Place a sphygmomanometer cuff around the patient’s arm above the elbow. Inflate to
_____________ and keep it at this pressure throughout the test.
❖ Clean the area with _____ ethanol and allow to dry.
❖ Select a site on the patient’s forearm approximately ___________ with below the bend in the
elbow that is free of visible subcutaneous veins.
❖ A sterile disposable blood lancet is use to make two shallow incisions about __________ deep.
❖ The punches must be performed within ____________ seconds of inflation of blood pressure
cuff simultaneously start the stopwatch. Do not wipe the blood.
❖ After ______________ blot the blood with the filter paper, the filter paper must not touch the
wound on the arm, blot the site at regular ___________ intervals.
❖ Rotate the filter paper after each ______________.
❖ When bleeding ceases and blot no longer is drawn to the filter paper, stop the stopwatch and
release the blood pressure cuff by turning the knob next to the bulb in the opposite direction
use to inflate the cuff.
❖ Remove the blood pressure cuff.

✓ Record the bleeding time for both puncture sites.

✓ Average of readings is ___________________.
✓ Bleeding continues for > 15 minutes, procedure is _____________ and
__________ is applied
✓ Repeat the test on the other arm.
✓ If bleeding not ceased results are reported as > 15 minutes.
✓ Carefully ___________ the site after bleeding has stopped.
✓ ______________ all used materials.

❖ Normal range: _____________ minutes

Quality Control:

▪ Accomplished through standardization of procedure

▪ Wound is of standard length and depth
▪ Constant pressure of 40 mmHg is maintained throughout the procedure

Sources of Error:

o ______________________ - Aspirin intake 7 to 10 days prior to the procedure

o _____________________________ - too shallow, too deep and inappropriate location
o Alcohol is completely dried before making the puncture
o Residual alcohol - _________________________
o Results are adversely affected if timing is not initiated simultaneously