BLOOD (PLATELETS) Dr.

Olivar

PLATELETS (THROMBOCYTES) -just like RBC, the main sources of platelets are the Pluripotent Hematopoietic Stem Cell (PHSC) in the bone marrow. -The precursor of platelets is called MEGAKARYOCYTES. -very big cells which fragments to minute platelets. PLATELETS -DESCRIPTION: small, non-nucleated, colorless bodies -main function: to achieve hemostasis -Size: 1-4 um. -Normal Values: 150,000 300,000 = Thrombocytopenia (more important) -decreased platelets = abnormal bleeding -ex: Dengue = Thrombocytosis FUNCTIONS: Hemostasis 1. Releases thromboxane A2 LOCAL VASOCONSTRICTION 2. Formation of PLATELET PLUG 3. Participates in BLOOD COAGULATION 4. Clot Retraction (by secreting Thrombosthenin") HEMOSTASIS prevention of blood loss 3 Mechanisms: LOCAL VASOCONSTRICITON -a reflex response from local myogenic contraction of the blood vessel -1st line in hemostasis -to prevent blood loss *PLEASE REMEMBER* Substances released by PLATELETS aiding in local vasoconstriction: a. Thromboxane A2 b. Serotonin * the 2 substances that helps the blood vessels to constrict in the 1 st line of hemostasis c. Factor 13: Fibrin Stabilizing Factor (FSF) PLATELET PLUG FORMATION Damaged vascular surface (exposed collagen from endothelium) Platelets are attracted to the area Platelets swell, grow pseudopods, sticky, forms thromboxane A2 PLATELET PLUG FORMATION -important in controlling/closing numerous minute fractures in many small blood vessels that may occur many times daily

-They dont have enough platelets that can perform the function of platelet plug formation. BLOOD COAGULATION -3rd mechanism for hemostasis -GOAL: to form a CLOT Mechanism of Coagulation 3 Essential Steps: 1. The formation of PROTHROMBIN-CONVERTING ENZYME or prothrombin activator -readily converts prothrombin to thrombin -(*RATE-LIMITING STEP*; PROTHROMBIN ACTIVATOR is the RATE LIMITING ENZYME) -once formed, Step 2,3 will automatically occur fibrin (clot) -with the help of CALCIUM and PLATELET PHOSPHOLIPIDS Step2 2. The conversion of PROTHROMBIN to THROMBIN by this agent. -thrombin readily converts fibrinogen to fibrin 3. The conversion of FIBRINOGEN to FIBRIN clots thru the action of THROMBIN.

PROTHROMBIN ACTIVATOR is generated Prothrombin is readily converted to thrombin under the help of calcium and platelet phospholipid Thrombin once generated, will convert fibrinogen to fibrin * the first fibrin generated from this reaction is just a fibrin monomer (not a stable clot) The fibrin monomer must polymerize as fibrin polymer through FIBRIN STABILIZING FACTOR (Factor XIII) -released by platelet -activated by thrombin Once polymerized, it forms CLOT (composed of fibrin polymers running in all directions trapping within RBCs, PLATELETS and PLASMA) STOP BLEEDING

-IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP): decreased platelet counts -Manifestations: multiple lesions/hemorrhages -Petechiae (smaller) -Purpura (bigger)
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BLOOD (PLATELETS) Dr. Olivar

CLOTTING FACTORS IN THE BLOOD AND THEIR SYNONYMS CLOTTING SYNONYMS FACTOR Factor I Fibrinogen Factor II Prothrombin Factor III Tissue Factor, Thromboplastin Factor IV Calcium Proaccelerin, Labile Factor, Ac-globulin Factor V (Ac-G) Serum prothrombin conversion Factor VII accelerator (SPCA), Proconvertin, Stable Factor Antihemophilic factor A, Antihemophilic Factor VIII factor (AHF); antihemophilic globulin (AHG) Antihemophilic factor B, Plasma Factor IX thromboplastin component (PTC), Christmas factor Factor X Stuart-Power Factor Antihemophilic factor C, Plasma Factor XI thromboplastin antecedent (PTA) Factor XII Hageman Factor, Contact Factor Factor XIII Fibrin Stabilizing Factor (FSF) Prekallikrein Fletcher Factor Fitzgerald Factor, HMWK (high-molecularHMMK weight kininogen) platelet *MEMORIZE! *NO FACTOR VI -these coagulation factors are plasma proteins; they are synthesized mostly in the liver. -they exist in blood vessel (plasma) in INACTIVE FORM. -whenever the vessel is damaged, and one of the factors is stimulated, they are converted to ACTIVE ENZYMES eventually forms the clot by converting fibrinogen to fibrin EVENTUAL GROWTH OF FIBROUS TISSUE INTO THE BLOOD CLOT TO CLOSE THE HOLE IN THE VESSEL PERMANENTLY

EXTRINSIC PATHWAY

Stimulated by trauma to the vascular wall and adjacent tissues Starts with the release of Factor 3 (Tissue Factor/ Thromboplastin) combines with Factor7 F3 + F7 = activates Factor 10 to ACTIVATED FACTOR 10A Activated F10A converts Prothrombin to Thrombin Thrombin converts Fibrinogen to Fibrin Hence, the PROTHROMBIN ACTIVATOR is ACTIVATED FACTOR 10A FACTOR 5 accelerates the action of activated Factor 10A in converting Prothrombin to Thrombin * The action of F5 is possible if it is stimulated by THROMBIN - significance: the extrinsic pathway to begin with is very slow until the first thrombin is generated once generated, it activates F5 action of prothrombin activator is enhanced (factor 10) Extrinsic pathway only makes two factors: Factor3 and Factor7 to generate the prothrombin activator. Extrinsic factor is short because tissue trauma is the one stimulating this.

INITIATION OF THE CLOTTING PROCESS Trauma to the vascular wall and adjacent tissues (EXTRINSIC) Contact of the blood with damaged endothelial cells/ collagen (INTRINSIC) Trauma to the blood (INTRINSIC) * EXTRINSIC and INTRINSIC pathways generate the PROTHROMBIN ACTIVATOR.

BLOOD (PLATELETS) Dr. Olivar

INTRINSIC PATHWAY

*When blood is placed in these test tubes, the blood will not clot because Ca++ is removed. Without Ca++, both extrinsic and intrinsic pathways will not occur. NO CLOT FORMATION. *Purpose of ANTI-COAGULANTS. REVIEW/OVERVIEW: PLATELETS. FUNCTIONS: Hemostasis 1. LOCAL VASOCONSTRICTION 2. Formation of PLATELET PLUG 3. Participates in BLOOD COAGULATION 4. Clot Retraction (by secreting Thrombosthenin") CLOT RETRACTION -4th function of platelets. -Serum

It is stimulated by contact of the blood with damaged endothelial cells/ collagen; trauma to the blood Starts with Factor12 Activates Factor11 Activates Factor9 Activated F9 + Activated F8 = converts F10 to Activated Factor10A Again, Activated Factor10A is the Prothrombin Activator HEMOPHILIA Lacks FACTOR8. Without F8, nothing can combine with F9 cannot convert F10 to Activated F10A. Makes them prone to bleeding.

When blood is placed in a tube that does not contain an anticoagulant, soon it will clot. After sometime, the clot will retract and it will extrude the serum. The blood clot that retracted, all coagulation factors are included. Serum has no coagulation factor. Clot retraction is a function of platelets because platelets secrete a substance called THROMBOSTHENIN. Platelets also have actin and myosin causing the platelets to contract. When the clot retracts, the serum is extruded and all the coagulation factors are in that clot. The SERUM CANNOT CLOT because the clotting factors are all trapped in the clot.

COMPARED WITH PLASMA If plasma is placed in a tube with anti-coagulant and placed in a centrifuge, plasma will separate with RBCs. Plasma contains coagulation factors, plasma can CLOT. * SERUM cannot clot; produced by putting in a plain tube * PLASMA can clot; produced if the blood is anticoagulated

BOTH IN EXTRINSIC AND INTRINSIC PATHWAY, CALCIUM AND PLATELETS ARE INVOLVED IN THE REACTION. Even if the coagulation factors are complete, WITHOUT CALCIUM AND PLATELETS, the coagulation pathways will NOT OCCUR or will be impaired bleeding It is rare to decrease the Calcium level in the blood. However, we can remove the Calcium from the blood by placing it in a tube with anticoagulant. BLUE TOP: contains CITRATE - de-ionizes Calcium GRAY TOP: contains OXALATE precipitates Calcium

BLOOD (PLATELETS) Dr. Olivar

As the clot retracts, the edges of the broken blood vessel are pulled together, thus contributing still further to hemostasis. When clot is formed no bleeding; but vessel is still damaged Clot needs to retract so the edges will be pulled together to reepithelialize = purpose of Clot Retraction = function of Platelets Purpose of clot in a damaged vessel: PREVENT BLOOD LOSS Purpose of clot in a repaired vessel: NONE CLOT SHOULD BE LYSED LYSIS OF BLOOD CLOT

INTRAVASCULAR ANTICOAGULANTS: 1. Endothelial Surface Factors Because the endothelium of blood vessels is smooth due to the layer of glycocalyx, there is no clotting because the clotting factors are repelled by the glycocalyx.

Thrombin in the circulation Function of Thrombomodulin: binds to any Thrombin that is circulating inactivates thrombin Thrombomodulin + Thrombin = Protein C (another anticoagulant) deactivates Factor5, Factor8 * When blood vessels are smooth, it will not clot because it will repel the coagulation factors

Plasminogen (INACTIVE in plasma) Once the vessel has repaired itself, t-PA is released by the damaged endothelial cells converting plasminogen to PLASMIN Plasmin will dissolve the clot PURPOSE OF PLASMIN: to dissolve the fibrin fibers including coagulation factors to remove clots from the vessels FUNCTIONS OF PLASMIN: Digest fibrin fibers Digest fibrinogen, Factor 5, 8, 12 and prothrombin *PLASMIN dissolves the clot *t-PA only accelerates the conversion of plasminogen to plasmin Tissue Plasminogen Activator: ex. Streptokinase, Urokinase o CASE: Heart attack - cause: clot develops in major coronary supply of the heart blocks the blood flow - if given with Streptokinase immediately converts plasminogen to plasmin plasmin will dissolve the clot re-establish blood flow to remove the clots from the vessels that eventually would become occluded where there is no way to clean them. Clotting does not occur normally because of the presence of intravascular anti-coagulants. In normal conditions (blood vessels are not damaged, anticoagulants pre-dominate more than pro-coagulants.

*When the smoothness of the endothelium is damaged, the glycocalyx and thrombomodulin factors are negated, thus clot occurs * Once collagen is exposed, it stimulates Intrinsic Pathway beginning with Factor12 forms thrombus 2. Anti-thrombin action of fibrin and anti-thrombin III FIBRIN itself deactivates the THROMBIN formed. Anti-thrombin III, together with Heparin = causes the blood not to clot. Heparin

3.

COAGULATION DISORDERS: 1. COAGULATION DEFICIENCY- bleeding a. Bleeding caused by Vitamin K deficiency VITAMIN K: continuously synthesized by the normal flora in the intestine. Factors 9, 10, 7, 2 = dependent on VitK for them to be produced Protein C

Liver produces plasma proteins or the coagulation factors. But for Factors 9,10,7,2 to be activated, LIVER CARBOXYLASE enzyme uses VitaminK. ONCE the factors ACTIVATED, VITAMIN K is oxidized and rendered NON-FUNCTIONAL.
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BLOOD (PLATELETS) Dr. Olivar

Vitamin K Epoxide Reductase Complex1 (VCOR c1) reduces back VitK to its functional form. VitK is a fat-soluble vitamin For it to be absorbed, it has to be absorbed with fat To absorb fat, bile is needed from the liver NO bile NO fat absorption NO vitK absorption

ATHEROSCLEROTIC PLAQUE -accumulation of cholesterol crystals beneath the intimal layer of the blood vessel. -Manifestations: Hypertension because the blood vessel diameter is decreased. -Danger: atherosclerosis can rupture breaks into the lumen of the blood vessel collagen is exposes stimulates Intrinsic Pathway (F12) formation of clot blocks blood flow infracted tissue EMBOLISM - exemplified by a clot developing on the deep veins of the leg - accumulation of thrombus can be carried away by the blood embolus - travels up to the main vessels inferior vena cava lungs PULMONARY EMBOLISM - usual origin of pulmonary embolism: DEEP VEINS of the legs - it will lodge on the PULMONARY CAPILLARIES because the vessels are VERY SMALL - after OR, early ambulation is necessary because tasis of blood can cause formation of clots

CAUSES OF VITAMIN K DEFICIENCY: Liver diseases - cannot synthesize plasma proteins - cannot secrete bile cannot absorb fat cannot absorb vitK Blockage in the production of bile - If gall bladder is removed, there will be NO bleeding problems because LIVER is the one producing BILE - Problems in bleeding will only arise if common hepatic duct is cut bile cannot flow to the intestine no fat absorption no vitK absorption bleeding problems. Seen among newborns - GIT is still sterile - 1st: dry the baby; 2nd: inject vitK - to prevent intracerebral hemorrhage among newborns Hemophilia - lacks Factor8 (85%); Factor9 (15%) - Male ONLY; sex-linked disease - Disease resides in the X-chromosome - FEMALE are never affected because they have two (XX); the other X can compensate; CARRIERS ONLY - MALE offspring are affected because they only have one (XY); once affected, patient manifest hemophilia - TREATMENT: give RECOMBINANT FACTOR8 (very expensive) Thrombocytopenia

b.

c. 2.

* Any clot originating from the deep vein of the legs, is it possible to see the clot on the left side of the heart? - in normal conditions: No, because clot will just be stuck in the pulmonary artery - in Tetralogy of Fallot: Yes, there is reversal of flow; R ventricular pressure is greater than the L ventricle - in Atrial Fibrillation: spontaneously a clot can be developed in the mitral valve Activated Factor10A that can be stimulated by intrinsic and extrinsic pathway Both pathways can activate the prothrombin activator Cleaves factor2 to thrombin Cleaves factor1 to fibrin st 1 result is a fibrin monomer; must polymerize to become a stable clot which is brought about by factor13 Fibrin polymers trap within are RBC, platelets, plasma The clot formed in the mitral valve can be thrown again as an embolus CEREBRAL VESSELS most common cause of stroke
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COAGULATION EXCESS- abnormal clotting a. Thrombus: an abnormal clot that develops in a blood vessel -When clots are carried away by the blood flow embolus b. Emboli: freely flowing clots -blocks blood flow; tissue is devoid of blood flow infarcted Infarct: tissue devoid of blood supply

c.

Blood Vessel Layers: - Tunica Intima: location of atherosclerotic plaque- SUB-INTIMAL layer - Tunica Media - Tunica Adventitia

BLOOD (PLATELETS) Dr. Olivar

* Deep vein Pulmunory embolism * Left side of the heart Stroke DISSEMINATED INTRAVASCULAR COAGULATION - a clotting mechanism which becomes activated in widespread areas of the circulation - CAUSES: a. Sepsis - cause: bacterial toxins - when there is overwhelming infection, the toxins generated by the bacteria can stimulate the clotting mechanism clotting widespread in the circulation - TREATMENT: massive antibiotics b. Abruptio placenta - premature detachment of placenta - placenta is a tissue; a good source of Tissue Factor or Factor3 which can stimulates Extrinsic Pathway D.I.C. - Pathophysiology: widespread stimulation of the coagulation pathway which will produce clots in the circulation body will sense it and produce massive PLASMIN (fibrinolysin) to lyse the clot but since the placenta is still present, it will generate another widespread clotting plasmin will lyse again (VISCIOUS CYCLE of clot-lysis) until coagulation factors are already consumed results to bleeding = D.I.C. aka CONSUMPTIVE COAGULOPATHY -TREATMENT: - remove the PLACENTA - supportive transfusions: (coagulation factors in the form of:) fresh frozen plasma, cryoprecipitate - anti-coagulants must NOT be given in DIC because giving of anti-coagulants will accelerate death due to bleeding ANTI-COAGULANTS FOR CLINICAL USE 1. HEPARIN - produced naturally by basophils - MODE OF ACTION: potentiates the action of ANTITHROMBIN III - in itself is not a good anti-coagulant; if combined with naturally-occurring ANTI-THROMBIN III (Heparin-Antithrombin Complex) blocks FACTORS 12, 11, 9, 10, 2 - ANTIDOTE: PROTAMINE SULFATE

2.

COUMADIN/ WARFARIN -MODE OF ACTION: block the action of Vitamin K

Blocks the action of VCOR c1 enzyme Vitamin K will not be reduced back to its functional form NO VitK = NO coagulation factors will be produced BLOOD COAGULATION TESTS: to assess the coagulation competency of an individual. 1. BLEEDING TIME - fingertip is pricked - time bleeding lasts (when the bleeding will stop) - Normal Value: 1-6 minutes - Operator-dependent; this method was abandoned; no longer used * TEST for QUALITY of PLATELETS: if platelets are of good quality, they will perform platelet plug formation bleeding will stop * TEST for QUANTITY of PLATELETS: Platelet Count (CBC) 2. CLOTTING TIME - putting blood in a non-anticoagulated test tube (plain tube) - time needed for blood to clot is assessed - Normal Value: 6-10 minutes

*TEST FOR CLOTTING FACTORS 3. PROTHROMBIN TIME (PT) - TEST for QUANTITY of PROTHROMBIN in the blood (EXTRINSIC PATHWAY) - Normal Value: 12 seconds [PET] PARTIAL THROMBOPLASTIN TIME (PTT) - TESTS the INTRINSIC PATHWAY of coagulation [PITT]

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