This document discusses bleeding, clotting, and related abnormalities. It covers the mechanisms of hemostasis, the clotting cascade, factors involved in clotting, causes of bleeding disorders, investigations for bleeding and clotting abnormalities, and treatment approaches. The key points are: bleeding can be external or internal; hemostasis involves vascular spasm, platelet plug formation, and blood clotting; clotting is a cascade of coagulation factors; abnormalities can cause excessive clotting (thrombosis) or bleeding; investigations include blood tests and imaging; treatment depends on the specific disorder but aims to replace any deficient clotting factors.

1. BLEEDING AND CLOTTING
ABNORMALITIES
SUPREET KUMAR

2. BLEEDING

3. WHAT IS BLEEDING ???
Bleeding, technically called as
HAEMORRHAGING is the loss or
escape of blood from the
circulatory system…
BLEEDING CAN EITHER BE :-

4. 1) EXTERNAL
2) INTERNAL

5. TYPES OF BLEEDING
A) CLASS I HAEMORRHAGE : 10-15 % of blood
volume
B) CLASS II HAEMORRHAGE : 15-30 % of blood
volume
C) CLASS III HAEMORRHAGE : 30-40 % of blood
volume
D) CLASS IV HAEMORRHAGE : > 40 % of blood
volume

6. CAUSES OF BLEEDING
A)TRAUMA
- Lacerations
- Incisions
- Contusions
- Crush injuries
B)UNDERLYING MEDICAL CONDNS
- Anatomical defects
- Cancer & infections
- Disorders of hemostasis
- Drugs & Anticoagulation therapy

8. A DELICATE BALANCE

9. HEMOSTASIS
HEMOSTASIS is the co-ordinated sequence of
events that eventually stops the bleeding..
EFFECTIVE HEMOSTASIS :-
A) Response should be rapid
B) Response should be localised to the region of
damage
C) Response should be carefully controlled

10. MECHANISMS THAT REDUCE
BLOOD LOSS
THERE ARE 3 IMP MECHANISMS :-
1) VASCULAR SPASM
2) PLATELET PLUG FORMATION
> Platelet adhesion
> Platelet release action
> Platelet aggregation
3) BLOOD CLOTTING

14. CLOTTING

15. BLOOD CLOTTING
DEFINITION :
The process of formation of jelly like substance over
the ends and within the walls of the blood vessels,
with the resultant stoppage of blood flow ..
> Clotting involves a series or a cascade of
chemical reactions that culminates in formation of
FIBRIN THREADS.
> Clotting involves specific substances known as the
CLOTTING FACTORS.

16. CLOTTING FACTORS
NUMBER NAME OF FACTOR SOURCE ACIVATION
I FIBRINOGEN LIVER COMMON
II PROTHROMBIN LIVER COMMON
III THROMBOPLASTIN PLATELET EXTRINSIC
IV CALCIUM IONS PLATELET
& BONE
ALL PATHWAYS
V LABILE FACTOR LIVER &
PLATELET
EXTRINSIC
AND
INTRINSIC
VII PROCONVERTIN LIVER EXTRINSIC
VIII ANTIHEMOPHILIAC
FACTOR A
LIVER INTRINSIC

17. CLOTTING FACTORS
NUMBER NAME OF THE
FACTOR
SOURCE ACTIVATION
IX ANTIHEMOPLHILIAC
FACTOR B
LIVER INTRINSIC
X STUART-PROWER
FACTOR /
THROMBOKINASE
LIVER INTRINSIC AND
EXTRINSIC
XI PLASMA
THROMBOPLASTIN
ANTECEDENT
LIVER
INTRINSIC
XII HAGEMAN FACTOR LIVER INTRINSIC
XIII FIBRIN STABILISING
FACTOR
LIVER AND
PLATELETS
COMMON
PATHWAY

18. THE CLOTTING CASCADE
CLOTTING is a complex cascade of enzymatic reactions in
which each clotting factor activates many molecules of the
next one in a fixed sequence…
CLOTTING CAN BE DIVIDED INTO 3 STAGES
1) THE 2 pathways : EXTRINSIC & INTRINSIC Leading to
formation of PROTHROMBINASE
2) PROTHROMBINASE converts PROTHROMBIN into
enzyme THROMBIN
3) THROMBIN converts soluble FIBRINOGEN into insoluble
FIBRIN

20. SOME FAQs
1) WHAT IS THE NEED FOR 2 PATHWAYS ??
2) WHAT ARE THESE EXTRINSIC AND INTRINSIC
PATHWAYS ??
3) WHY ARE THEY CALLED SO ??
4) HOW DOES THE INSOLUABLE FIBRIN FORMED IN
THE LAST STEP OF THE CASCADE LEAD TO CESSATION
OF BLEEDING ??

21. CLOT RETRACTION
ONCE the clot is formed
IT plugs the ruptured area of blood vessel & thus stops
further bleeding
CLOT RETRACTION is the consolidation of the fibrin
clot
AS the clot retracts , it pulls the edges of the damaged
vessels close to each other and bridges the gap caused
due to the trauma or injury and hence leads to arrest of
bleeding

22. HEMOSTATIC CONTROL MECHANISMS
REGULATION of hemostasis is of optimum
importance
The body has an in built mechanism to CONTROL
AND REGULATE the process of hemostasis.
1) THE FIBRINOLYTIC SYSTEM
2) PROSTACYCLIN
3) NATURAL ANTI COAGULANTS IN BLOOD

23. WHY DOESN’T THE BLOOD CLOT
WHILE FLOWING THROUGH THE
VESSELS ??
1) THE ENDOTHELIAL LINING OF THE VESSEL
2) AXIAL FLOW OF THE BLOOD
3) VELOCITY OF THE BLOOD FLOW
4) NATURAL ANTICOAGULANTS

24. DYSREGULATION OF THE
HEMOSTATIC MECHANISM …
> CLOTTING is a dynamic process that involves
AMPLIFICATION and POSITIVE FEED BACK CYCLE.
> DYSREGULATION in the control mechanism can
lead to uninhibited clotting and hence a large clot called
THROMBUS is formed.
> THROMBUS has the potential to clog the vessels
and impair the blood flow that has hazardous
consequences.

25. THROMBUS FORMATION
VIRCHOW’S
TRIAD
ENDOTHELIAL INJURY
STASIS OF
BLOOD
HYPER
COAGULABI
LITY

26. VENOUS THROMBI : INITIAL
PHASE

27. MASSIVE THROMBUS IMPAIRING
BLOOD FLOW

28. VESSEL OCCLUDED BY THE THROMBUS

29. AN APPROACH TO BLEEDING DISORDERS
1) HISTORY
* Site of bleeding
* Duration of bleeding
* Precipitating factors of the bleeding
* History of previous operative procedures
* Family history
* History of drug intake
2) EXAMINATION
* Look for BRUISES,PURPURA,TELANGIECTASIA
* Examination of joints ( HAEMOPHILIA )
* stigmata of liver diseases
* SPLEENOMEGALY ( indicates thrombocytopenia )

30. MANAGEMENT OF BLEEDING
DISORDERS
INVESTIGATIONS TREATMENT

31. INVESTIGATIONS IN CASE OF A BLEEDING
DISORDER
* PLATELET COUNT
* BLEEDING TIME
* CLOTTING TIME
* PROTHROMBIN TIME
* ACTIVATED PARTIAL THROMBOPLASTIN TIME
* FIBRINOGEN LEVEL
* CLOT RETRACTION TIME
* ACTIVATED CLOTTING TIME
* PLASMA THROMBIN TIME

32. TREATMENT MODALITIES
* TREATMENT IS DEPENDENT ON THE TYPE OF
BLEEDING DISORDER
* THE MAIN AIM OF THE TREATMENT IS TO
REPLACE THE COMPONENT OR THE FACTOR
WHOSE DEFICIENCY LEADS TO BLEEDING

33. AN APPROACH TO CLOTTING DISORDERS
1) HISTORY
* Careful history taking is important for evaluation
* Family history should be enquired about
2) EXAMINATION
Careful evaluation of the signs and symptoms
* Pain
* swelling
* Redness at the site and other relevant symptoms

34. INVESTIGATIONS FOR ABNORMAL CLOTTING
OR THROMBOTIC DISORDERS
1) BLOOD EXAMINATION
* D- DIMER
* CBC
* COAGULATION STUDIES BT,CT,APTT,FIBRINOGEN
* LIVER ENZYMES
2) IMAGING STUDIES
* DOPPLER
* ULTRASOUND
* DUPLEX AND THERMOGRAPHY

35. TREATMENT MODALITIES FOR ABNORMAL
COAGULABILITY
ANTI-THROMBOTIC DRUGS ARE THE DRUGS USED FOR
TRAETMENT OF HYPER COAGULABILITY
ANTI THROMBOTIC DRUGS
ANTI PLATELET
DRUGS
ANTI
COAGULANTS
FIBRINOLYTIC
AGENTS

36. ANTI PLATELET DRUGS
1) ASPIRIN
2) THIENOPYRIDINES
* CLOPIDOGREL
* TICLOPIDINE
3) DIPYRIDAMOLE
4) GP II b / III a RECEPTOR ANTAGONIST
* ABCIXIMAB
* TIROFIBAN

37. ANTI COAGULANTS
1) HEPARIN
2) LMW HEPARIN
3) FONDAPARINUX
4) DIRECT THROMBIN INHIBITOR
* LEPIRUDIN
* BIVALIRUDIN
* ARGATROBAN

38. FIBRINOLYTIC DRUGS
1) STREPTOKINASE
2) UROKINASE
3) ALTEPLASE
4) TENECTEPLASE
5) RETEPLASE
6) ANISTREPLASE