止血与血栓PPT课件

Examination of Hemostasis & ThrombusMechanism of Hemostasis小血管、微血管(smll vessel)血小板(Platelet)凝血系统(Coagulation Protein System)抗凝系统(Anticoagulation Protein System) 纤溶系统(Fibrinolysis System)抗纤溶系统(Antifibrinolysis System)1. HemostasisCoagulation Activation BV InjuryPlatelet Activation Plt-Fusion Blood VesselConstrictionStable Hemostatic PlugThromibin,FibrinReducedBlood flow Tissue FactorPrimary hemostatic plug NeuralCapillary Wall止血的过程Platelet System：粘附功能（Adhesion）聚集功能（Aggregation）释放功能（Release）5Contact Tissue Factor + VII XIII a XIII ThrombinFibrin(strong)Fibrinogen Fibrin (weak)IX XIXI aIX a X a V aXII a Prothrombin TF-VII a (Prothrombinase)PL PL(Tenase)VIII a PL X Intrinsic PathwayHK aExtrinsic Pathway Common Pathway TF PathwayCoagulation PathwaysProtein C, Protein S, Antithrombin III凝血的过程内源性凝血IntrinsicXIIaXIa Xa III VIIaCa 2+VIIIaCa 2+IXa PF3Va PF3Ca 2+外源性凝血Extrinsic IIa Ia Ib XIIIFDP（四）Anticoagulation System：1、from Cell：Monocytes-Macrophage cells2、from tissue：AT-III、Protein C、Protein S、TFPI。

1) AT-III: II，IX，X，XI，XII et al2) PC, PS：Va, VIIIa et al;3) TFPI (tissue factor pathway inhibitor)（五）Fibrinolysis and Anti-fibrinolysis◆Plasminogen activator：XIIa，IIa，HMWK，prekallikrein，uPA，tPA，PL◆Anti-fibrinolysis：PAI, a2-APcoagulation FibrinolysisvesselplateletAnti-coagulation Anti-fibrinolysisHomeostasis止血与凝血性疾病的分类血管因素血小板数量和质量异常凝血因子异常纤溶蛋白溶解亢进病理性循环抗凝物质增多实验室检查 （一）血管壁的检测CRT，BT（二）血小板的检测PLT（三）凝血因子的检测CT,APTT,PT（四）抗凝物质的检测TT，AT-III（五）纤溶系统的检测3P, D-dimer（一）血管壁的检测1、Capillary fragility(resistance) test, CFT/CRT 【Diseases】petechia or blood points1)、Abnormal structure or function of vessel wall: e.g.allergic purpura, hereditary hemorrhagictelangiectasia(HHT)2)、Platelet disease: ITP3)、von Willebrand’s Disease2、Bleeding Time【Diseases】BT prolonged1）Low count of Platelet: e.g. ITP2）Dysfunction of Platelet: e.g. Thromasthenia 3）blood vessel diseases: e.g. HHT(hereditary hemorrhagic telangiectasia)4）anticoagulation drugs:aspirin（二）Platelets count【Reference value】（100～300）×109／L 【Diseases】1）Thrombocytopenia：e.g. ①generation reasons: AA；②destruction or consumption: ITP, SLE, DIC、tumors;③distribution: liver cirrhosis2）Thrombocytosis：e.g. Thrombocytosis(CML)Intrinsic 12,11,9,8(aPTT-)Extrinsic-7(PT)Prothrombin →ThrombinFibrinogen →FibrinCommon Path (TT)FX →FXaScreening Tests for Coagulation Disorders（三）Examination for coagulation factors 1、Activated Clotting Time【Princple】The whole blood clotting time is a rough measure of all intrinsic clotting factors in the absence of tissue factors.2、Activated Partial Thromboplastin Time, APTT【Ref Ranger】32～43s，10s over control。

【Interpretation】I, II, V, VIII, IX, X, XI, & XIIcoagulation factor deficiency (e.g. hemophilia A, B, C)use of heparinantiphospholipid antibody (especially lupus anticoagulant)3、Prothrombin time, PT【Ref Ranger】11～13s，3s over control 【Interpretation】the extrinsic pathway of coagulation:V, X Vitamin K deficiency:II,VII,IX,XLiver failureDICuse of warfarinISI：为国际敏感度指数（International Sensitivity Index）的缩写，是用多份不同凝血因子水平的血浆与国际参考制品（IRP）作严格的校准，通过回归分析求得回归斜率而得到的，代表凝血活酶试剂对凝血因子缺乏的敏感性，ISI值越低则敏感性越高，进口凝血活酶试剂均标有ISI值，可用此值计算出INR值。

ISI越接近于1.0，其检测结果越准确。

1.3、INR：为国际标准化比率（International NormalizedRatio）的缩写。

用凝血活酶所测得的参比血浆与正常血浆的PT比值和所用试剂标出的ISI值计算出INR，使不同的凝血活酶试剂测得的结果具有可比性。

INR计算：INR=PTRISI 或INR=antilog（ISI×lgPTR）（五）纤溶系统的检测1、Plasma Protamine Paracoagulation test 【Priciple】sFM+FDPs=SFMC Soluble Fibrin Monomer Complex【Ref】negative【Interpretation】primary fibrinolysis : Negativesecondary fibrinolysis: Positive or NegativeSYSTEMIC ACTIV ATIONOF COAGULATIONIntravascular deposition of fibrin Depletion of platelets and coagulation factors Thrombosis ofsmall and midsizevessels BleedingOrgan failure DEATHDICD isseminatedI ntravascularC oagulationATIII Clotting Factors Tissue factor *PAI-1AntiplasminTFPI Prot. C Prot. SProcoagulant AnticoagulantFibrinolytic System2、laboratory test for DIC 1）PLT < 100×109／L2) Fg<1.5g/L 3）PT>3s4）3P(+) 5) D-dimer Screening Test Confirm?Thrombocytopenia▪plat count <100,000 or rapidly decliningProlonged clotting times (PT, APTT)Presence of Fibrin degradation products or positive D-dimerLow levels of coagulation inhibitors▪AT III, protein CLow levels of coagulation factors▪Factors V,VIII,X,XIIIFibrinogen levels not useful diagnosticallyEarly diagnostics test：PAP，FPA，F1+2，TAT….出血性疾病实验室检测的选择一期：Blood Routine，BT，CRT二期：APTT，PTDIC的诊断血栓前状态：APTT，PT，Fg，AT:A，FDP，D-D病例某患者，男性，20岁，肘关节反复肿痛出血就诊。