Building Schemata with Major Haem, Lethal Triad and Clotting

In a patient with 25% red blood cells component of blood, they are likely to present with: a. Breathing issues from low levels of plasma b. Light-headedness from lack of 02 reaching the brain c. Clotting issues from lack of platelets d. Infections from less white blood cells 2. Following a...

In a patient with 25% red blood cells component of blood, they are likely to present with: a. Breathing issues from low levels of plasma b. Light-headedness from lack of 02 reaching the brain c. Clotting issues from lack of platelets d. Infections from less white blood cells 2. Following a stabbing, a patient presented with bleeding from the wound. Which of the following is an indication that this is a major haemorrhage? a. Loss of 50% blood volume in 24 hours b. Bleeding in excess of 100ml/minute c. Loss of 50% of blood volume in 2 hours d. A heart rate of 110BPM 3. Which of the following is a clinical indication of Major Haemorrhage? a. Heart rate of 110BPM b. BP of 80 mmHg c. heart rate above 110 bpm and systolic blood pressure below 90 mmHg d. heart rate above 100 bpm and systolic blood pressure below 80 mmHg 4. During major haemorrhage, the body independently attempts to maintain homeostasis by: a. Baro-receptors communicating loss of volume to the kidneys b. Baro-receptors communicating loss of volume to the brain c. Chemoreceptors communicating loss of volume to heart d. Nicotinic receptors communicate loss of volume to lungs 5. The following responses occur as a result of loss in blood volume: a. Sympathetic (increased heart rate & contractility) & vasoconstriction b. Parasympathetic (decreased heart rate and contractility) & vasodilation c. Decreased cardiac output and increased systemic vascular resistance d. Decreased systemic vascular resistance and increased cardiac output 6. Baroreceptors are mainly situated in: a. Aortic arch b. Pharyngeal walls c. Blood vessels d. Subcutaneous tissue 7. In the intrinsic pathway of the clotting cascade, the following occurs: a. The clotting process is triggered through indirect damage of blood vessels b. Internal damage causes loss of fluid from circulation c. The clotting process is triggered by direct damage to blood vessels d. Collagen triggers fibrin causing a temporary clot 8. In the Extrinsic pathway of the clotting cascade, the following is correct: a. The clotting process is triggered through indirect damage of blood vessels b. The clotting process is triggered by direct damage to blood vessels c. Collagen activates platelets forming a temporary clot d. Potassium plays a key role in the clotting process 9. During an investigation of clotting factors, the patient had depleted thrombin. Which of the following will not be activated: a. Prothrombin & Calcium b. Prothrombin & Fibrin c. Platelets & Fibrinogen d. Calcium & Fibrinogen 10. In a massive transfusion of red blood cells, clotting will be impaired due to: a. Citrate binding to calcium impairing clotting cascade b. Citrate binding to thrombin impairing clotting cascade c. Less factor 13 impairing formations of clot d. Citrate impairing structure of Fibrin from less fibrinogen 11. During a major haemorrhage, which of the following is unlikely: a. Coagulopathy b. Metabolic acidosis c. Hypothermia d. Hyperthermia 12. During major haemorrhage, the following is rapidly used up: a. Enzymes which break down clots b. Enzymes which prolong clots c. Enzymes which stimulate formation of clots d. Enzymes which form the clots 13. Tranexamic Acid should be given within: a. The first 3 hours to activate enzymes in forming clots b. The first 3 hours to impair the enzyme ability to break down clots c. The first 6 hours to activate enzymes in forming clots d. The first 6 hours to impair the enzyme ability to break down clots 14. During major haemorrhage: a. 02 is lost causing anaerobic respiration b. 02 is lost causing respiratory alkalosis c. 02 is lost causing aerobic respiration d. 02 is lost causing the production of ATP-C02-H2O 15. During Major Haemorrhage, an altered PH could cause: a. Limited response to treatment b. disfunction of enzymes c. Cardiac arrythmias d. All of the above 16. During Major haemorrhage, normothermia is impaired by: a. Peripheral vasoconstriction preventing 02 rich blood and clotting factors reaching peripheries b. Peripheral vasodilation preventing 02 rich blood and clotting factors reaching peripheries c. Reduced blood volume causing hyperthermia d. Central vasoconstriction preventing 02 rich blood and clotting factors reaching core organs 17. On recognition of major haemorrhage (while waiting for blood products), fluid replacement involves: a. 2 litres of colloid fluid aiming for baseline BP b. Restricted crystalloid fluid replacement aiming for target (lower) BP c. No fluid, inotropes & vasopressors only d. Restricted crystalloid fluid replacement aiming for baseline BP 18. The aim of the treatment for major haemorrhage should be to eliminate: a. The lethal triad consisting of coagulopathy, metabolic alkalosis, hypothermia b. The lethal triad consisting of calcium, metabolic alkalosis, hypothermia c. The lethal triad consisting of coagulopathy, metabolic alkalosis, hyperthermia d. The lethal triad consisting of coagulopathy, metabolic acidosis, hypothermia 19. Cryoprecipitate is administered to patients during major haemorrhage as: a. It is spun from platelets so contains more fibrinogen than platelets alone b. is spun from FFP and so contains a lot more fibrinogen than FFP c. is spun from red blood cells so contains more erythrocytes to carry 02 d. is spun from FFP so contains more 02 carrying capacity 20. During massive transfusion, the following is administered: a. Calcium to activate clotting b. Potassium to manage cardiac arrhythmias c. Insulin for aerobic respiration d. Warfarin aiming for an INR of 1.2 21. During a major haemorrhage, an ODP is involved in: a. Arranging relevant blood products and drugs b. Warming the patient c. Assisting with regular arterial blood gases d. All of the above 22. During major haemorrhage, hypocalcaemia could cause: a. The formation of clots b. A regulated PH c. Increased cardiac contractility d. Decreased cardiac contractility 23. In a major haemorrhage situation, a rapid sequence induction and intubation (mechanic ventilation) is indicated early as: a. Rapid bleeding causes aerobic respiration b. Rapid bleeding causes loss of respiratory function c. Rapid bleeding causes anaerobic respiration d. Rapid bleeding causes loss of 02 rich blood 24.. For Active Bleeding IN HOSPITAL: (**Select TRUE of FALSE) (2 marks)** a. Hartmann's Solution or 0.9% NaCL is the product of choice to replace fluid volume b. Tranexamic Acid IV is given to prevent excess clotting c. IV Fluid replacement should be restricted in uncontrolled haemorrhage d. A ratio of 2 Red Blood Cells : 1 Fresh Frozen Plasma should be adhered to if laboratory coagulation results are available 25. In relation to the Lethal Triad: **(Select TRUE of FALSE) (2 marks)** a. The elements are: ACIDOSIS, COAGULOPATHY, HYPOTHERMIA b. The priority of treatment is early prevention of blood loss c. An IV infusion of Adrenaline 1 in 10, 000 should be started to reverse the acidosis d. IV calcium may be indicated 26. With regards to blood products used during transfusion: **(Select TRUE of FALSE) (2 marks)** a. in the absence of group specific blood, A Negative Red Blood Cells should be used b. 1 pooled unit of Cryoprecipitate contains MORE fibrinogen than 2 units of Fresh Frozen Plasma (FFP) c. Platelets must be the same blood group as the patient d. Plasminogen may be needed to enhance the formation of a clot 27. During Major Haemorrhage: **(Select TRUE of FALSE) (2 marks)** a. The average circulating blood volume of an adult is 30 -- 40 ml/kg b. Active bleeding of \>150ml/min and/or loss of half total circulating blood volume in 3 hours are criteria for declaring Major Haemorrhage c. Tranexamic Acid (TxA) 1g is given immediately to prevent the breakdown of a clot d. Blood should be transfused cold to avoid hyperthermia 28. In the uncontrolled haemorrhage: **(Select TRUE of FALSE) (2 marks)** a. High volume crystalloid should be administered b. Damage Control Surgery may be used to stabilise the patient c. Clotting should be promoted by administering Warfarin or Aspirin d. Hypotension (systolic BP less than 100mmHg) should not be permitted Use previous exam paper question for Mock exam (1) -------------------------------------------------- Case Studies: ============= You have been called to A&E resus for a 58-year-old male patient bleeding from a wound on his upper leg (femoral region) after an accident with an electric saw while cutting down a tree in his garden. As A&E are extremely busy, you have been called down as the ODP on call for an initial assessment and management under your scope of practice. The following are the observations available: A -- patient is talking and complaining of pain B -- RR 28, equal bilateral air entry and chest movement, SpO2 94% C -- HR 120, BP 80/50, CRT 3 seconds D --A on AVPU, no abnormal posturing, glucose 3.9 mmol/l, pale, cool peripherally E -- open wound exposing femoral bone, blood covering clothing and dripping on bed sheet (lower half of bedding covered in blood-not dripping to floor) **Critically analyse the clinical management for this patient presenting with major haemorrhage and apply the anatomy and pathophysiology based on the presenting clinical assessment (30 marks)** C: Catastrophic bleed-control bleeding-apply pressure dressing with sterile swabs and dressing-open wound-femoral bone A: Patent B: RR is high linked to pain and anaerobic respiration-attempt to shift C02 from depleted 02 from loss of volume- link to homeostatic mechanisms of metabolic acidosis. Attempt to prevent (lethal triad) as this could cause, dysfunction of enzymes, drugs and cardiac function. No imminent concerns with breathing, but be prepared for intubation with rapid sequence for mechanical ventilation (Ventilation/perfusion)-not fasted. Sp02 94% low-high flow 100% 02 via non-rebreathing mask for maximum 02 while awake and lower c02 rebreath C: HR 120-high from homeostatic response (increased HR) for low stroke volume to maintain cardiac output-triggered by baroreceptors in carotid/aorta and as a sympathetic response from adrenergic receptors. Also, a clinical indication of major haemorrhage alongside systolic BP: 80/50: systolic lower than 90 (clinical indication of major haem) indicated by loss of excessive blood not manageable by increased HR and SVR as a sympathetic response-indicating depleted volume. Crystalloid fluid should be administered or prepared if not prescribed. Prepare vasopressors/inotropes for vascular constriction. Clinical indications of Major Haem. Activate protocol (Call for help, blood products (RBC, Cryc, Platelets, FFP). 0 negative blood until blood arrive (give reasons)x. Consider Calcium and tranexamic acid within 3 hours. Explains reasons for each CRT 3 seconds-should be 2 so is slow indicating low perfusion D: Alert-glucose slightly low-may be related to starvation period and trauma. Pale/cool peripherally occurring from loss of blood-peripheral vasoconstriction hence pale. Active warming-link to lethal triad as enzymes wont work and needed for clotting and drugs and PH. E: Open wound, exposed bone. Escalate as per NEWS2. May require stabilisation surgery as physiology must be stabilised before repair surgery.