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Bleeding time,clotting time,

PT, and PTT





Dr.Haya Al-Ghazali
Hemostasis or haemostasis :
is a complex process which causes the
bleeding process to stop. It refers to the
process of keeping blood within a
damaged blood vessel.
Hemostasis is maintained in the body
via three mechanisms :
Vascular spasm - Damaged blood vessels
constrict.
Platelet plug formation - Platelets adhere to
damaged endothelium to form platelet plug
(primary hemostasis) and then degranulate.
Blood coagulation - Clots form upon the
conversion of fibrinogen to fibrin, and its
addition to the platelet plug (secondary
hemostasis).

THE CLOTTING MECHANISM
INTRINSIC EXTRINSC
PROTHROMBIN THROMBIN
FIBRINOGE
N
FIBRIN
(II) (III)
(I)
V
X
Tisue Thromboplastin Collagen
VII
XII
XI
IX
VIII
FIBRINOLYTIC PHASE
ANTICLOTTING MECHANISMS ARE ACTIVATED
TO ALLOW CLOT DISINTEGRATION AND
REPAIR OF THE DAMAGED VESSEL.
HEMOSTASIS
DEPENDENT UPON:

Vessel Wall Integrity
Adequate Numbers of Platelets
Proper Functioning Platelets
Adequate Levels of Clotting Factors
Proper Function of Fibrinolytic Pathway
So What Causes Bleeding Disorders?

VESSEL DEFECTS

PLATELET DISORDERS

FACTOR DEFICIENCIES
VESSEL DEFECTS
VITAMIN C DEFICIENCY
BACTERIAL & VIRAL INFECTIONS
ACQUIRED
PLATELET DISORDERS

THROMBOCYTOPENIA
(INADEQUATE NUMBER OF PLATELETS)
Causes
DRUG INDUCED
BONE MARROW FAILURE
HYPERSPLENISM
OTHER CAUSES
THROMBOCYTOPATHY
)ADEQUATE NUMBER BUT ABNORMAL
FUNCTION (.

causes
UREMIA
INHERITED DISORDERS
MYELOPROLIFERATIVE DISORDERS
DRUG INDUCED(ASPIRIN, NSAIDS)
FACTOR DEFICIENCIES
Inherited:
1. HEMOPHILIA A

2. HEMOPHILIA B

3. VON WILLEBRANDS
DISEASE

Acquired:

1. Anticoagulant
therapy

2. Liver diseases

3. DIC
LABORATORY EVALUATION
PLATELET COUNT
BLEEDING TIME (BT)
PROTHROMBIN TIME (PT)
PARTIAL THROMBOPLASTIN TIME (PTT)
THROMBIN TIME (TT)
PLATELET COUNT (CBC)
NORMAL 100,000 - 400,000
CELLS/MM
3

< 100,000

Thrombocytopenia

50,000 - 100,000 Mild Thrombocytopenia

< 50,000 Sever Thrombocytopenia


BLEEDING TIME

PROVIDES ASSESSMENT OF
PLATELET COUNT AND FUNCTION


NORMAL VALUE
2-8 MINUTES
PROTHROMBIN TIME
Measures Effectiveness of the Extrinsic
Pathway

NORMAL VALUE
10-15 SECS
PT
The prothrombin time: is therefore the time required for the plasma
to clot after an excess of thromboplastin and an optimal
concentration of calcium have been added.

Measures the function of the Extrinsic Pathway.

Sensitive to Factors I, II, V, VII, X.

The PT evaluates patients suspected of having an inherited or
acquired deficiency in these pathways.

THE CLOTTING MECHANISM
INTRINSIC EXTRINSC
PROTHROMBIN THROMBIN
FIBRINOGE
N
FIBRIN
(II) (III)
(I)
V
X
Tisue Thromboplastin Collagen
VII
XII
XI
IX
VIII
When is it ordered?
Used to monitor oral anticoagulant therapy (Warfarin /
Coumadin).

When a patient who is not taking anti-coagulant drugs
has signs or symptoms of a bleeding disorder.

When a patient is to undergo an invasive medical
procedure, such as surgery, to ensure normal clotting
ability.
An elevated prothrombin time may indicate
the presence of:
Vitamin K deficiency
(Vitamin K is needed to make prothrombin and other clotting factors)
DIC
liver disease
a deficiency in one or more of the following factors:
I, II, V, VII, X.
Anticoagulant (warfarin)


INR
A PT test may also be called an INR test.
INR (international normalized ratio) stands for a way of
standardizing the results of prothrombin time tests, no
matter the testing method.
So your doctor can understand results in the same way
even when they come from different labs and different
test methods.
Using the INR system, treatment with (anticoagulant
therapy) will be the same. In some labs, only the INR is
reported and the PT is not reported
An INR of 1.0 means that the patient PT is normal.
An INR greater than 1.0 means the clotting time is
elevated.
INR of greater than 5 or 5.5 = unacceptable high risk of
bleeding,whereas if the INR=0.5 then there is a high
chance of having a clot.
Normal range for a healthy person is 0.91.3, and for
people on warfarin therapy, 2.03.0, although the target
INR may be higher in particular situations, such as for
those with a mechanical heart valve.
PARTIAL THROMBOPLASTIN TIME
Measures Effectiveness of the Intrinsic
Pathway
NORMAL VALUE
25-40 SECS
PTT
The partial thromboplastin time (PTT) or activated partial
thromboplastin time (aPTT or APTT (is a performance
indicator measuring the efficacy of both the "intrinsic"
and the common coagulation pathways.

It is also used to monitor the treatment effects with
heparin a major anticoagulant .

Kaolin cephalin clotting time (KccT) is a historic name for
the activated partial thromboplastin time
THE CLOTTING MECHANISM
INTRINSIC EXTRINSC
PROTHROMBIN THROMBIN
FIBRINOGE
N
FIBRIN
(II) (III)
(I)
V
X
Tisue Thromboplastin Collagen
VII
XII
XI
IX
VIII
Normal PTT times require the presence of
the following coagulation factors:
I, II, III, IV, V, VI, VIII, IX, X, XI, & XII
When is it ordered?
When a patient presents with unexplained bleeding or
bruising,

It may be ordered as part of a pre-surgical evaluation for
bleeding tendencies,

When a patient is on intravenous (IV) or injection heparin
therapy, the APTT is ordered at regular intervals to
monitor the degree of anticoagulation.
Prolonged APTT may indicate:
use of heparin.

antiphospholipid antibody:especially lupus anticoagulant ,
which paradoxically increases propensity to thrombosis

coagulation factor deficiency ,
e.g hemophilia
DIC
Liver disease

THE CLOTTING MECHANISM
INTRINSIC EXTRINSC
PROTHROMBIN THROMBIN
FIBRINOGE
N
FIBRIN
(II) (III)
(I)
V
X
Tisue Thromboplastin Collagen
VII
XII
XI
IX
VIII
FACTOR DEFICIENCIES
Inherited:
1. HEMOPHILIA A

2. HEMOPHILIA B

3. VON WILLEBRANDS
DISEASE

Acquired:

1. Anticoagulant
therapy

2. Liver diseases

3. DIC
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
VON WILLEBRANDS DISEASE
Deficiency of VWF & amount of Factor VIII
Factor VIII is bound to vWF while inactive in
circulation; Factor VIII degrades rapidly when not
bound to vWF
Lab Results - Prolonged BT, PTT

ANTICOAGULANTS
An anticoagulant is a substance that prevents
coagulation; that is, it stops blood from clotting
This prevents deep vein thrombosis, pulmonar
embolism, myocardial infarction and stroke.

ANTICOAGULANTS
1. Coumadins (Vitamin K antagonists)
2. Heparin

Coumadins

These oral anticoagulants that antagonize the effects of
vitamin K.
Examples include warfarin. It takes at least 48 to 72
hours for the anticoagulant effect to develop. Where an
immediate effect is required, heparin must be given
concomitantly.
Monitored by PT times
These anticoagulants are used to treat patients with
deep-vein thrombosis (DVT), pulmonary embolism (PE),
atrial fibrillation (AF), and mechanical prosthetic heart
valves.

Heparin
Heparin is a biological substance.
It works by activating antithrombin III, which blocks
thrombin from clotting blood.
Heparin Therapy is Monitored by PTT times
Low molecular weight heparin is a more highly
processed product that is useful as it does not require
monitoring of the APTT coagulation parameter (it has
more predictable plasma levels) and has fewer side
effects.
Liver Disease
Liver Disease can Result in Reduced
Production of Coagulation Factors
(I,II,V,VII,IX,X).
DIC
Disseminated intravascular coagulation ( DIC is a
pathological activation of coagulation )blood clotting)
mechanisms that happens in response to a variety of
diseases
DIC leads to the formation of small blood clots inside the
blood vessels throughout the body
The small clots also disrupt normal blood flow to organs
(such as the kidneys), which may malfunction as a result
As the small clots consume coagulation proteins and
platelets, normal coagulation is disrupted and abnormal
bleeding occurs from the skin the gastrointestinal tract,
the respiratory tract and surgical wounds.
The PT and APTT are usually very prolonged and the
fibrinogen level markedly reduced
High levels of fibrin degradation products, including D-
dimer, are found owing to the intense fibrinolytic activity
stimulated by the presence of fibrin in the circulation.
Definitive diagnosis depends on the result of DIC:

Thrombocytopenia )prolonged bleeding time)
Prolongation of prothrombin time and activated partial
thromboplastin time
A low fibrinogen concentration
Increased levels of fibrin degradation products

Platelet
count
Bleeding
time
Partial
thromboplastin
time
Prothrombi
n time
Condition
unaffected prolonged prolonged unaffected Von Willebrand disease
unaffected unaffected prolonged prolonged
Vitamin K deficiency or
Warfarin
unaffected prolonged unaffected unaffected Uremia
unaffected unaffected prolonged unaffected Haemophilia
unaffected unaffected prolonged prolonged Factor V deficiency
unaffected prolonged unaffected unaffected Aspirin
decreased prolonged unaffected unaffected Thrombocytopenia
decreased prolonged prolonged prolonged End-stage Liver failure
decreased prolonged prolonged prolonged
Disseminated intravascular
coagulation
decreased prolonged unaffected unaffected Bernard-Soulier syndrome


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