 Hello everybody, how are you doing today? Today we're going to talk about Bleeding disorders this is one of the biggest Topics I think students need to get a good grasp on For if you ever shadowed a hematologist, you got to remember this stuff man. This is crazy man I keep it straight. Yeah, that's true because they got a trig man, and they never tell you And that's you have to give credit to dr. Barone because he taught us this for medical boards I want you to first of all split your brain to two Okay Into two so you can understand what bleeding disorders is all about If you're watching this video right now, and you don't understand the cloud and cascade And you don't understand the platelet plug cascade Please please go back click down here and go back to the cloud and cascade video So you can understand what we're about to talk about right now So we're gonna split our brain to two and from now on to two forever and ever and ever is gonna be two brains, okay? On one side of our brain right here. It's gonna be platelets platelets only platelets On this side of the brain Coagulation factor dysfunction. That's all I want you to know for now You split your brains into platelet problem Clotin factors coagulation factors. They're two different things Remember to let them make the hemorrhage primary moustache Right and these guys are gonna make the fiber in a gin into fibering and everything's gonna come together So let's start Patients are gonna come into the hospital and they're gonna tell you they're bleeding You're gonna be like Okay What am I supposed to do now? Yeah. Yeah, there's something because the thing you know the answer And now we're gonna figure out by the end of this lecture the first you have to understand it Is it a political problem? Or are they missing some coagulation factors? We don't know So they're gonna come in with this on this side of the brain This is the only breaks part of the brain we are working with right now platelets. See platelets coagulation factors I try to draw a map of the brain One part for several of my the other parts where we can view the same page They're gonna come with superficial bleeding. That's the history doc. I noticed I have this little little dots on my skin They call them PT care PT care They might have something called ecchymosis or a perp from now on till that kingdom come anytime you have perperechymosis PT care Always think platelets PT care. It's gonna be a board to gonna say all I have some particularly collision of pop people perpere People proper it sounds like something like doing the platelets always remember that meningococcusemia sepsis DIC we're gonna talk about that platelets platelets PT care Ecchymosis PT kids tiny little duck Hammer ages you see on the like under the skin tiny little duck if you get a little wider It becomes an ecchymosis. It's kind of a sweet spread. Okay, and perpere. It's more even widespread Okay, look the picture up on Google and you'll see it. Don't give you a idea picture. Okay, cuz when you see a patient Or this attack, you know, my nose is bleeding. I have nosebleeds You don't know if it's a blood problem. You don't know if it's a quad religion problem You've got to find out what you tell your dog. My message is ridiculous. I'm bleeding like crazy Menoragi That's all mucus membrane. Okay, endothelial bleeding Skin mucus skin popular perpere ecchymosis PT care Menoragi nosebleeds, right? So when they come into your doctor's office into the matters and you're like, you know, what do I order first? Since you're thinking platelet the first order is what got a CBC When you got a CBC, which is a complete blood count You'll give you the platelet count. You want to know what their platelet count is We're back in the days, you know, how they used to know, um, if you have a platelet problem We use something called the bleeding time. Do you know what the bleeding time is? It's the time it takes you for you to bleed until you stop. I think that is crazy, right? Like I'll cut you. Let me see how long it takes you for you to bleed. Okay. Oh Actually is not cool because the way to test it. They'll take blades Put it on a scale and it's nick your skin. It's not and it's not the time Hmm, let me see how long it takes you to bleed. I don't think any of you guys really I'm gonna show them They're not gonna do that on me for sure. No way. Okay. So when you have bleeding time, I Was a complete problem Now we're gonna take our brains a little big brain and split it into two There's two things that can happen. I can actually have low platelets with your terminology of medicine It's called what thrombo? Right, so we're gonna split this into two now. I can have low platelets Which we call thrombo? Cytopenia Did you see that? low platelet Let's see. What can cause low platelets? Hmm a lot of things can cause low platelets, right? But what I want you to know there's two three that's three things in medicine That's always like there. They'll test you in your bed boards. You're gonna be like, oh good. Not again It's remember this three things the first one is itp Idiopathic which means we don't know what causes it thrombo cytopenia to ttp thrombotic thrombocytopenia We're gonna I'm not gonna talk about the pathogenesis of this disease because that's a whole lecture on its own and the third one HUS hemolytic uremic syndrome this is a classic three Thrombocytopenic syndromes you need to come into memory. This is extremely important But every time you see low platelet so which means if their platelet is low what you expect a bleeding time to be If I don't have any platelets and remember the EMS to come to the spot cuz they are low I'm gonna be bleeding a lot. I mean bleeding time will be extremely hot right Remember those three things keep that into memory for now Another thing that can also cause low platelets Is hip Heparin Induced thrombo cytopenia is basically making antibodies against platelets and heparin which also consumes your platelets Which I'm not really going to go into details because that's another lecturing zone But remember this four things because we're gonna talk about that pathology and pathophysiology later on down the line however Actually, I might have platelets and it might not be working Can you believe it actually have normal platelet count and By the way, what is your normal platelet count? It's between 150 to 400,000 ML keep it millimeters. Just remember that number. You have to know that eventually. Okay, I Can have a normal platelet, but they're not working. How can that be possible? I have platelets, but they're not working. Let's see. How can that happen a patient on aspirin? How does aspirin work? Oh Let's show you remember the arachidonic acid aspirin is gonna block Cyclooxygen is one and two which means I can't make what? Thromboxin A2 remember the last lecture 3% A2 does what? Plated aggregation if the pressure can't come together and worth it So I do have no more platelets, which means what's gonna happen to my bleeding time. It's gonna be high Not because I don't have platelets It's because the blisters are there, but they just not working right this nobody to spread the perfume to attract them to come I know the reason I can actually have normal platelets and they're not working is this Uremia Uremia classic a 40 year old diabetic patient on you know hasn't gone to dialysis for so long He can't exceed all those BUN. I mean the urea out of their body The urea actually comes and colts around the platelets So if you caught the platelets the antibodies can't stick out and stick to each other So everybody's just playing around and have no more platelets. However, they're not working They can't stick together. None of those glycoproteins are working at that point know that See how easy this is so I can actually have low platelets my bleeding I'm bleeding a lot having all the syndromes. Oh, I can have no more platelets However They're not cloudy Now we can have genetic disorders the three genetic disorders you have to know and actually We're gonna go over them. And if you don't remember what I told you always remember go back And if you listen to this like always go back to cloudy caskets understand the first one is better severe very rare disease I Don't even think I see my lifetime which is a glycoprotein 1b deficiency Glycoprotein 1b remember is needed for you to buy to all those von Willebrand So if there's no glycoprotein 1b von Willebrand just be staying there, and you're still gonna be bleeding, okay? How do I remember Benage to their better start with what I like this guy? It's not gonna be So I turn glycoprotein 1b Remember I see a normal platelets the platelets are normal there the probably problem is they can't bind Another tool is glas man from both side opinion That's man. It's gonna be a deficiency in glycoprotein 2b 3a That's the same like remember that glycoprotein I told you about that needs to cause platelet aggregation if they're not there You can produce it if you have a deficiency remember if the places gonna come together you're still gonna keep bleeding You need those two in between a fiber agent to hold them together, and if they're not that oops But look at it my platelet can is still normal, but wasn't happy bleeding time It's gonna be high because I'm gonna keep bleeding because there's no platelets to stick to each other I Know the problem could be what I can have normal platelets But how about this? Vaughn will it be a factor is on vacation This patient is gonna come in with Mucous membrane it's classic both questions gonna tell you it's nosebleeds. They have a patechia. They have a menorrhagia Right in 19 or 15 year old girl is having these problems Vaughn will it bring factor and we're gonna talk about the clinical significance in the pathology later But this is what you got to remember Vaughn will it find if there's no Vaughn will it bring remember those Vaughn will it bring You need those like a protein 1b to bind to Vaughn will it bring if they're not there You're gonna still bleed See how easy this is so if you commit this to memory, so just a bit of sorry. We're still working on the Right is this superficial bleeding think platelet Patechia Echemosis bop people perforate, right? nosebleeds menorrhagia Or the cbc stack look at the platelet count is the plant got normal or is it low if it's low go into this little little extra pathway itp ttp h us and HIT they might be an help ring Remember if the patients are happening. Oh, we got a problem Or is the patient platelet normal if it's normal it's either I didn't ask if they're not aspirin But I'm giving the answer I don't dialysis and you have my dialysis in the white. They're diabetic. They got uremia Do they have been a slayer very rare glensman thrombocytopenia very rare Vaughn will it bring factor deficiencies But what it's gonna be different but Vaughn will it bring is this So this is just Vaughn will it bring okay Vaughn will it bring disease? What is the platelet count? Normal platelets are normal. What is the bleeding time? It should be high right why because There is no platelets to bind to Vaughn. There's no Vaughn will it be factor to bind to remember However Remember Vaughn will it bring is the husband in factor 8 is the wifey if I'm willing to run it's not around We're gonna be missing factor 8 remember factor 8 is that guy told you right there? Let's convert factor 9 into factor 10 in the intrinsic pathway Right, so if there's no factor 8, what will you expect the p t t to be? Elevated that's why people with only one factor. That's high p t t. How about the p t? Will it be normal of normal loop or hot? It should be normal. It's p t remember p t is dependent on the extra is it we're going to war right? It's 1972 cool factors has nothing to do with the this cute little mnemonic I give you 11 9 10 2 1 right 7. This is where 8 is and this is where 5 is this is the guy That's missing factor 8. So this guy is gonna be p t t is gonna be high So when you are the cbc You should expect political to be normal However p t t should be high. They're bleeding because bleeding time But we don't we don't do bleeding time anymore, but this is a classic board question. This is the way it is Okay, and we are done It's over platelets platelets switch up brains It's locked that and go to the left hand side of our brains. We are going to coagulation factors This is coagulation factors not platelets not platelets. This is coagulation factors Okay coagulation factors at the factors. I just wrote on the board is fellas 12 11 9 10 2 1 7 right with little bit of factor 8 and little bit of factor 5 here this All these bad boys have the coagulation factors. What's the point in life? They're pointing to convert five or not getting to vibrate make a nice static plug If one of these guys is a missing one This reaction is not gonna happen. It's not going to happen, right? Everybody came to the party except this guy forget it. The party's not gonna do go on So this is what we're talking about here How is the vision is gonna present this is gonna come to the hospital, right? They're gonna have deep bleed It's gonna be deep in the tissues I want you to sing along with me. He my Toma. He my cross. He my throes is quite good Loppy he my Toma. He my cross is quite good. Loppy He my Toma. He my cross. He my throes is quite good. Loppy He my Toma. He my Toma. He my Toma. He my Toma. He my Throes is in Atthrosis in Atthrosis bleeding in the joints bleeding in the joint him at home Bleeding in the tissues in my Toma. It's gonna be on your boards. They're gonna write it there The guy is bleeding in his joints, right? Any little thing they hit. They're bleeding. They hit. They're bleeding Why are they bleeding? He my Toma. He my throes. They just don't throw what's around. It's the reason You hear that word. You're like good luck back there. Good luck. I'm not a singer. Okay, that's not the point What do you order? I want to order a stat cbc I'll check the blood let's do Because I don't know where it's coming from, but I want to see what the PT and your PTT Looks like so they're gonna have patients with easy bleeding The funny thing is this guy also have easy bleeding is because the scratchy nose any bleeding I'm an iridescent bleeding, but this guy's not easy bleeding But what makes these guys different is the he my Toma. He my throes is quite a lot of feet So I order a PTT and a PT And the first thing I think of it's gonna be like this the first disease Hemophilia is he's not the word in it. He more him a failure Hemophilia is a factor 8 deficiency That means if factor 8 is missing this guy right here So let's think about factor 8 is missing. What would you play let's count? No more. It's nothing to do with pleasure. This is flakless What is bleeding time? It's gonna be what? It's gonna be high a little bit. Why because they're not clotting. Well, it's actually gonna be normal a little bit But if you touch them, they're gonna bleed What are you gonna expect the PTT PTT to be the PTT PTT? It's gonna be high cuz factor 8 is missing What you think it's gonna be the PTT PTT is gonna be normal Right, so factor 8 is Gonna cause what a high PTT a platelet count is gonna be normal and Bleeding time is gonna be no more cause what will happen is the platelet are gonna stick in people stick together Right, except you have von Willebrand missing the place is gonna be able to stick to von Willebrand You're gonna do the other thing, but you know what we can't co-op it Another disease is what? Hemophilia. This is called hemophilia a is hemophilia B Factor 9 deficiency with back to the same story That tonight's missing. We can feel this right and that's also a hemophilia C Which is factor 11 Can you see This is usually in Jews and it's always males Don't mess that that wrong you always touch a male that's having bleeding their joints always bleeding in their You know arms and their legs easy bruising every time they jump and they hit something they have blue breathing Check for factor 8 deficiency and how do we treat it? Oh, we give the fact I eat back. I like that You give them factor 8 back. Okay? So that's the three things I want you to first remember Another thing that you should be worried about is vitamin K deficiency Right If somebody doesn't have vitamin K, which I told you is needed to activate factor in 1972 Right How can we not have vitamin K usually a kid a newborn that's baby that's born has no vitamin K in their gut There's no equal eye. They need equal eye to make vitamin K for us, right? And as we get better if they just not sitting in our book not doing anything, right? So we give them vitamin K shot, right? How can we not if you're not eating enough vitamin K? You're gonna be deficient Also, if you're warfarin, right if you're warfarin, what will happen is Actually, what they don't tell you is although we always say PT is gonna be high or INR Which is true because nine nine ten seven and two is missing, but think about nine Now it is on the what PTT pathway. So PTT is also slightly high Which is don't talk about Because it's slightly high, but it's not as high as PT PT PT pro thrombin time Because this is the pro thrombin time. Okay. So but you don't that's just a little extra information But the bottom line is PT is gonna be pro long. What about if you're warfarin? If you're warfarin, you're gonna need to be 12, 11, 9, and 10 by Actant Antitombin 3. So obviously PTT's gonna be what? Extremely hot Tell me one more thing we need to finish this lecture which I actually understand quite a lot Well, I don't even know what we're talking if so the guy that actually gives us all these cool factors in our life It's like a parents without you know a kid a little dog without a father It's just a woman himlessly right, right, you know, there's nobody to provide food for it. If the liver is dead liver cirrhosis Right, if you listen to the liver function test lecture that I made you realize one of the most important is the liver does It's what make vitamin K and mix all these cool factors at the factory So if the liver is going and it's not working you can be bleeding you check the PT Very hot Also, you don't have albumin also, but the problem is if you have liver problem Automatically you will actually bleed this has bring up brought us to the end of this lecture This is how hematologists think They make medical students nursing students. They make them look idiots But this is how they think and you sit in there like oh my god, I can't figure this out is too much stuff But this is it summary bleeding disorders platelets Coagulation factors platelets coagulation factors are left and your right right in the left side of your brain Okay, play that problem superficially. Okay, they have epitoma. I'm sorry Echemosis Proper and you have to take care nosebleeds menorrhage Okay, labs your other planet count is it low if it's low think itp ttp h us h it If they're normal thing they aspirin they have uremia or they have been a civilian glens man of my own with a breath You're done Sit your brain coagulation factors think hematoma hematrhosis coagulopathy Okay, then you look at the class gas get which already memorized and stop picking and choosing what you want Hemophilia factor is out. Okay, it's usually males remember that fact the night fact Factor nine and factor 11 B and C. Okay vitamin K deficiency. Okay, think about it You're not gonna have you know vitamin K to make all this whole factors active PT is hot Leave your problems. Okay, PTT is to gonna be high. Okay And that is it That's it guys. I hope you enjoyed this lecture. Please subscribe to my videos and also visit our website FTP inc.org. Thank you very much for watching. Have a good day. Take it easy. God bless