HEMOSTASIS & BLOOD COAGULATION HANDOUTS IN PHYSIOLOGY MIDTERM PERIOD LEO EMMANUEL R. BUNAG, M.D.

FPSECP HEMOSTASIS -prevention of blood loss involving the following mechanisms: 1.vascular constriction 2.formation of platelet plug 3.formation of blood clot (result of blood coagulation) 4.eventual growth of fibrous tissue into the blood clot-for permanent closure of hole in vessel VASCULAR CONSTRICTION -contraction of smooth muscle in blood vessel wall -result of: 1.local myogenic spasm-causes more vasoconstriction; initiated by direct damage to vascular wall 2.local autacoids factors (from traumatized tissue & blood platelets*) 3.nervous reflexes-initiated by pain nerve impulse or other sensory impulses from traumatized blood vessels & nearby tissues *for smaller blood vessels by releasing a vasoconstrictor substance, thromboxane A2 PLATELETS (THROMBOCYTES) -minute discs 1-4 micrometers in diameter -formed in bone marrow from megakaryocytes -normal concentration in the blood = 150,000-300,000 per microliter -absence of nuclei & cannot reproduce -half-life om the b;ppd pf 8-12 days after which functional role ends -with active factors in the cytoplasm: 1.contractile proteins: actin & myosin & thrombosthenin 2.residuals of endoplasmic reticulum & golgi apparatus which synthesize enzymes & store large quantities of calcium ions 3.mitochondria & enzyme systems that form ATP & ADP 4.enzyme systems that synthesize prostaglandins causing vascular & local tissue reactions 5.fibrin-stabilizing factor, a protein with important role in blood coagulation 6.growth factor causing vascular endothelial cells, vascular smooth muscle cells & fibroblasts to grow & multiply causing cellular growth helping repair damaged vascular walls -cell membrane containing 1.a coat of glycoproteins repulsing adherence to normal endothelium but causing adherence to injured areas of the vessel wall 2.large amounts of phospholipids activating multiple stages in the blood clotting process -eliminated mainly by the tissue macrophage system; more than half are removed by macrophages in the spleen MECHANISM OF PLATELET PLUG -upon contact with damaged vascular wall they swell forming pseudopods, contractile proteins contract releasing granules with multiple active factors -become sticky to adhere to collagen in tissues & to a protein, Von Willebrand factor from the plasma -secrete large amount s of ADP and form thromboxane A2; these act on nearby platelets causing them to adhere to original activated platelets

-2-activate succeeding number of platelets to form platelet plug which is initially loose but later form fibrin threads providing stronge plug -important in closing very small ruptures in very small blood vessels BLOOD COAGULATION -clot begins to develop in 15-20 seconds when trauma is severe & in 1-2 minutes for minor trauma -initiator of clotting process:activator substances from 1.traumatized vascular wall 2.platelets 3.blood proteins adhering to traumatized vascular wall -within 3-6 minutes after rupture of vessel, entire opening or broein end of vessel filled with clot -after 20 minute-1 hour, clot retracts, closing the vessel further -platelet: important role in clot retraction FATE OF BLOOD CLOT 1.can become invaded by fibroblasts which form connective tissue all through the clot (usual course)( 2.can dissolve-by special substances within the clot which becomes activated; function as enzymes *promoted by growth factor secreted by platelets; continues to to complete organization of clot into fibrous tissue within 1-2 weeks MECHANISM OF BLOOD CLOT -caused by 50 substances grouped into procoagulants (promoting coagulation) & anticoagulants (inhibiting coagulation; clotting of blood depends on balance between the 2; in normal bloodstream, procoagulants dominate whiole in rupture vessel, anticoagulants dominate -3 essential steps: 1.activation of a cascade of chemical reactions involving blood coagulation factors; net result is the formation of activated substances (prothrombin activator) 2.prothrombin activator catalyzes conversion of prothrombin into thrombin 3.thrombin acts as an enzyme to convert fibrinogen intor fibrin fibers that enmesh platelets, blood cells and plasma to form clot CONVERSION OF PROTHROMBIN TO THROMBIN -formation of prothrombin activator result of rupture of blood vessel or damage to special substances in the blood -requirement for prothrombin activator to convert prothrombin to thrombin: calcium -rate-limiting factor in blood coagulation: formation of prothrombin activator -platelets: important role in converting prothrombin to thrombin PROTHROMBIN & THROMBIN -PROTHROMBIN =a plasma protein, an alpha2-globulin with molecular weight of 68,700 =concentration in normal plasma=15 mg/dl =unstable compound that splits into smaller compounds one of which is thrombin (which has a molecular weight of 33,700) =formed continually in the liver & used continually for blood clotting =requires vitamin K for normal activation of prothrombin together with clotting factors II, VII, IX, X & protein C

-3-lack of vitamin K and liver diseases prevent normal prothrombin formation resulting to bleeding tendency CONVERSION OF FIBRINOGEN TO FIBRIN -Fibrinogen =high molecular weight protein (MW=340,000) =concentration in the plasma: 100-700 mg/dl =site of formation: liver (liver diseases decreases concentration of fibrinogen) =little leaks out from blood vessels into the interstitial fluid; explains why interstitial fluid doesnt coagulate except when capillaries increase in permeability ACTION OF THROMBIN ON FIBRINOGEN TO FORM FIBRIN -Thrombin: a protein enzyme with weak proteolytic capabilities acting on fibrinogen to remove 4 low MW peptides from each molecule forming 1 molecule of fibrin monomer; this polymerizes into long fibrin fibers that form the reticulum of the blood clot -Fibrin-stabilizing factor: strengthens the fibrin reticulum adding covalent bonds BLOOD CLOT: composed of a meshwork of fibrin fibers running in all directions entrapping blood cellsk platelets and plasm CLOT RETRACTION -after formation, the clot contracts expressing most of the fluid as serum where fibrinogen & most of the other clotting factors have been removed; therefore, serum does not clot -role of plateletsin clot retraction -contributes further to hemostasis as the edges of the broken blood vessel are pulled together INITIATION OF COAGULATION: FORMATION OF PROTHROMBIN ACTIVATOR -clotting process initiated by the following complex mechanisms: 1.trauma to the vascular wall & the adjacent tissues 2.trauma to the blood 3.contact of the blood with damaged endothelial cells or with collagen & other tissue elements outside the blood vessel 1-3 leads to formation of prothrombin activator -Prothrombin activator formed in 2 ways 1.extrinsic pathway-begins with trauma to the vascular wall & the surrounding tissues 2.intrinsic pathway-begins in the blood itself *in 1 & 2, series of plasma proteins (blood clotting factors) play a major role by their conversion to their active forms EXTRINSIC PATHWAY FOR INITIATING CLOTTING -begins with a traumatized vascular wall or traumatized extravascular tissues coming in contact with the blood 1.Release of tissue factor or tissue thromboplastin-after trauma to tissues; composed of phospholipids from the membranes of the tissue plus a lipoprotein complex that functions as a proteolytic enzyme 2.Activation of Factor X to Factor Xa-role of Factor VII (Serum prothrombin conversion accelerator /proconvertin stable factor & tissue factor in the presence of calcium ions

3.Effect of Xa to form prothrombin activator-role of Factor V (Proaccelerin/labile factor/Ac globulin-

-4Factor Xa combines with tissue phospholipids (part of tissue factors) or with additional phospholipids released from platelets & with Factor V to form the complex prothrombin activator which splits prothrombin to form thrombin *Factor Xa: actual protease causing splitting of prothrombin to form thrombin *Factor Va: accelerates the protease activity *Platelets phospholipids: act as a vehicle to further accelerates the process *Positive feedback effect of thrombin: acting through Factor V to accelerate the entire process once it begins INTRINSIC PATHWAY FOR INITIATING CLOTTING -begins with trauma to the blood or exposure of the blood to collagen from a traumatized blood vessel wall 1.Blood trauma causes a.activation of Factor XII (Hageman Factor) b.release of platelet phospholipids (contain the lipoprotein platelet factor 3 which plays a role in subsequent clotting reactions 2.Activation of Factor XI (Plasma Thromboplasint Antecedent/Antihemophilic factor C-by Factor XIIa ; requires HMW (high molecular weight)kininogens & is accelerated by prekallikrein 3.Activation of Factor IX (Plasma thromboplastin component/Christmas Factor-by Factor Xia 4.Activation of Factor X (Stuart Factor/Stuart Prower Factor)-by Factor IXa acting with Factor VIII (Antihemophilic Factor/Antihemophilic globulin/Antihemophlic Factor a) & with platelet phospholipids & factor 3 from the traumatized platelets *Factor VIII-missing in patients with cvlassic hemophilia 5.Action of Factor Xa to form prothrombin activator-by Factor Va; this step is the same as the last step in the extrinsic pathway proceeding to formation of prothrombin activator ROLE OF CALCIUM IN THE INTRINSIC & EXTRINSIC PATHWAYS -calcium ions are required for promotion or acceleration of all the blood clotting reactions except the 1st 2 steps in the intrinsic pathway PREVENTION OF BLOOD CLOTTING IN THE NORMAL VASCULAR SYSTEM: INTRAVASCULAR ANTICOAGULANTS -most important factors: 1.smoothness of the endothelial cell surface-which prevents contact activation of the intrinsic clotting system 2.a layer of glycocalyx (mucopolysaccharide adsorbed to the surfaces of the endothelial cells) in the endothelium which repels clotting factors & platelets thereby preventing activation of clotting 3.a protein bound wioth the endothelial membrane, thrombomodulin, which binds thrombin ANTITHROMBIN ACTION OF FIBRIN & ANTITHROMBIN -most important anticoagulants in the blood that remove thrombin from the blood: 1.fibrin fibers that are formed during the process of clotting 2.an alpha globulin (antithrombin III or antithrombin-heparin factor

HEPARIN-combines with antithrombin III to increase the effectiveness of the latter -5-complex of heparin & antithrombin III: removes other activated clotting factors (IXX, IX , X and IX LYSIS OF BLOOD CLOTS: PLASMIN -Plasminogen or profibrinolysin: plasma protein euglobulin which is activated to become plasmin or fibrinolysin; this acts as a proteolytic enzyme resembling trypsin; it digests fibrin fibers & some other protein coagulants such as fibrinogen, Factor V, Factor VIII, prothrombin and Factor XII ACTIVATION OF PLASMINOGEN TO FORM PLASMIN, THEN LYSIS OF CLOTS -by release of a powerful activator (t-PA: tissue plasminogen activator) converting plasminogen to plasmin which in turn removes the remaining unnecessary blood clot CONDITIONS CAUSING EXCESSIVE BLEEDING IN HUMANS 1.Decreased Prothrombin, Factor VII, Factor IX and Factor X caused by Vitamin K deficiency & Diseases of the Liver 2.Hemophilia 3.Thrombocytopenia very low numbers of platelets THROMBOEMBOLISM -Thrombus: abnormal clot that develops in a blood vessel -Embolus: free flowing clots originating from thrombus detached from blood vessel wall by circulating blood; those that originate in: 1.large arteries or in the left side of the heart-flow peripherally & plug arteries or arterioles in the brain, kidneys or elsewhere 2.the venous system or in the right side of the heart-generally flow into the lungs to cause pulmonary arterial embolism -causes: 1.any roughened endothelial surface of a vessel as may be caused by atherosclerosis, infection or trauma (likely to initiate the clotting process) 2.blood often clots when it flow very slowly through blood vessels, where small quantities of thrombin & other procoagulants are always being formed -use of genetically engineered tissue plasminogen activator (t-PA): delivered directly to a thrombosed area through a catheter; effective in activating plasminogen to plasmin which dissolves some intravascular clots; spares the heart from serious damage if used within the 1st hour o so fater thrombotic occlusion of a coronary artery EndQuestions for my set for the Physio Lect Midterm will come purely from these handouts; lecture notes on Immunity no longer included..