CHAPTER36 Hemostasis and Blood Coagulation The term hemostasis means prevention of blood loss.

Whenever a vessel is severed or ruptured, hemostasis is achieved by several mechanisms: (1) vascular constriction (2) formation of a platelet plug (3) formation of a blood clot as a result of blood coagulation and (4) eventual growth of fibrous tissue into the blood clot to close the hole in the vessel permanently. Vascular Constriction the trauma to the vessel wall itself causes the smooth muscle in the wall to contract; this instantaneously reduces the flow of blood from the ruptured vessel. The contraction results from (1) local myogenic spasm(sudden contraction), (2) local autacoid factors from the traumatized tissues and blood platelets (release thromboxane A2), and (3) nervous reflexes. In platelets cytoplasm are such active factors as (1) actin and myosin molecules, which are contractile proteins similar to those found in muscle cells, and still another contractile protein, thrombosthenin, that can cause the platelets to contract; (2) residuals of both the endoplasmic reticulum and the Golgi apparatus that synthesize various enzymes and especially store large quantities of calcium ions; (3) mitochondria and enzyme systems that are capable of forming adenosinetriphosphate (ATP) and adenosine diphosphate(ADP); (4) enzyme systems that synthesize prostaglandins, which are local hormones that cause many vascular and other local tissue reactions; (5) an important protein called fibrin-stabilizing factor; and (6) a growth factor that causes vascular endothelial cells, vascular smooth muscle cells, and fibroblasts to multiply and grow. The cell membrane of the platelets:- On its surface is a coat of glycoproteins (repulses adherence to normal endothelium)causes adherence to injured areas-phospholipids that activate multiple stages in the blood-clotting process. When platelets come in contact with a damaged vascular surface, especially

"autocoids" are biological factors which act like local hormones

with collagen fibers in the vascular wall, the platelets begin to swell; they assume irregular forms with numerous irradiating pseudopods protruding from their surfaces; their contractile proteins contract forcefully and cause the release of granules that contain multiple active factors; they become sticky so that they adhere to collagen in the tissues and to a protein called von Willebrand factor that leaks into the traumatized tissue from the plasma; they secrete large quantities of ADP; and their enzymes form thromboxane A2. The ADP and thromboxane in turn act on nearby platelets to activate them as well, and the stickiness of these additional platelets causes them to adhere to the original activated platelets.

Platelet plug is at first a loose plug, but it is usually successful in blocking blood loss if the vascular opening is small. The clot begins to develop in 15 to 20seconds if the trauma to the vascular wall has been severe and in 1 to 2 minutes if the trauma has been minor. Activator substances from thetraumatized vascular wall-from platelets-blood proteins adhering to the traumatized vascular wall initiate the clotting process. Once a blood clot has formed, it can follow one of two courses: (1) It can become invaded by fibroblasts, which subsequently form connective tissue all through the clot, or (2) It can dissolve by enzymes in the clot. More than 50 important substances that cause or affect blood coagulation-promote coagulationprocoagulants -inhibit -anticoagulants. Three essential steps: (1) In response to rupture of the vessel or damage to the blood itself, a complex cascade of chemical reactions occurs in the blood involving more than a dozen blood coagulation factors. The net result is formation of a complex of activated substances collectively called prothrombin activator. (2)The prothrombin activator catalyzes conversion of prothrombin into thrombin. (3) The thrombin acts as an enzyme to convert fibrinogen into fibrin fibers that enmesh platelets, blood cells, and plasma to form the clot. Conversion of Prothrombin to Thrombinin the presence of sufficient amounts of ionic Ca++theratelimiting factor in causing blood coagulation is usually the formation of prothrombin activator and not the subsequent reactions beyond that point, because these terminal steps normally occur rapidly to form the clot itself. Platelets also play an important role in the conversion of prothrombin to thrombin because much of the prothrombin first attaches to prothrombin receptors on the platelets already bound to the damaged tissue. Prothrombin is a plasma protein, an alpha2-globulin.It is an unstable protein that can split easily into smaller compounds, one of which is thrombin. Prothrombin is formed continually by the liver, and it is continually being used throughout the body for blood clotting. Vitamin K is required by the liver for normal formation of prothrombin as well as for formation of a few other clotting factors. Fibrinogen (protein) is formed in the liver. Thrombin acts on fibrinogen to remove four low-molecular weight peptides from each molecule of fibrinogen, forming one molecule of fibrin monomer that has the automatic capability to polymerize with other fibrin monomer molecules to form

fibrin fibers. Therefore, many fibrin monomer molecules polymerize within seconds into long fibrin fibers that constitute the reticulum of the blood clot. Another process occurs during the next few minutes that greatly strengthens the fibrin reticulum. This involves a substance called fibrin-stabilizing factor that is present in small amounts in normal plasma globulins but is also released from platelets entrapped in the clot. Before fibrin-stabilizing factor can have an effect on the fibrin fibers, it must itself be activated. The same thrombin that causes fibrin formation also activates the fibrin-stabilizing factor. Blood Clot prevents further blood loss. Serum cannot clot because it lacks clotting factors. Plateletsbond different fibers together-platelets entrapped in the clot continue to release procoagulant substances, one of the most important of which is fibrin-stabilizing factor-activating platelet contractile proteins compress the fibrin mesh work into a smaller mass. The contraction is activated and accelerated by thrombin as well as by calcium ions released from calcium stores in the mitochondria, endoplasmic reticulum, and Golgi apparatus of the platelets. Vicious Circle of Clot Formation the clot itself initiates a vicious circle (positivefeedback) to promote more clotting. Reason: thrombin:-a direct proteolytic effect on prothrombin itself, tending to convert this into still more thrombin-acts on some of the blood-clotting factors responsible for formation of prothrombin activator-activate fibrin stabilizing factor-converts fibrinogen into fibrin monomers (1) trauma to the vascular wall and adjacent tissues, (2) trauma to the blood, or (3) contact of the blood with damaged endothelial cells or with collagen and other tissue elements outside the bloodvessel. In each instance, this leads to the formation of prothrombin activator. Prothrombin activator is formed in two ways: (1) by the extrinsic pathway that begins with trauma to the vascular wall and surrounding tissues and (2) by the intrinsic pathway that begins in the blood itself. Extrinsic Pathway for Initiating Clotting when a traumatized vascular wall or traumatized extravascular tissues that come in contact with the blood: 1. Release of tissue factor. (tissue thromboplastin)This factor is composed especially of phospholipids from the membranes of the tissue plus a lipoprotein complex that functions mainly as a proteolytic enzyme. 2. Activation of Factor X-role of Factor VII and tissue factor. 3. Effect of activated Factor X (Xa) to form prothrombin activator-role of Factor V. The positive feedback effect of thrombin, acting through Factor V, to accelerate the entire process once it begins 1. Blood trauma causes (1) activation of Factor XII and (2) release of platelet phospholipids. (contain the lipoprotein called platelet factor 3) 2.Activation of Factor XI by XIIa and HMW (high-molecular-weight) kininogen and is accelerated by prekallikrein.

3.Activation of Factor IX by XIa. 4.Activation of Factor X-role of Factor VIII. Factor VIII is the factor that is missing in a person who has classic hemophilia, for which reason it is called antihemophilic factor. Platelets are the clotting factor that is lacking in the bleeding disease called thrombocytopenia. 5. Action of activated Factor X to form prothrombinactivator-role of Factor V. Activated Factor X combines with Factor V and platelet or tissue phospholipids to form the complex called prothrombin activator. Except for the first two steps in the intrinsic pathway, calcium ions are required for promotion or acceleration of all the blood-clotting reactions. Tissue factor initiates the extrinsic pathway, whereas contact of Factor XII and platelets with collagen in the vascular wall initiates the intrinsic pathway. An especially important difference between the extrinsic and intrinsic pathways is that the extrinsic pathway can be explosive; once initiated, its speed of completion to the final clot is limited only by the amount of tissue factor released from the traumatized tissues and by the quantities of Factors X, VII, and V in the blood. With severe tissue trauma, clotting can occur in as little as 15 seconds. The intrinsic pathway is much slower to proceed, usually requiring 1 to 6minutes to cause clotting. Prevention of Blood Clotting in the Normal Vascular System Intravascular Anticoagulants Endothelial Surface Factors. Probably the most important factors for preventing clotting in the normal vascular system are (1) the smoothness of the endothelial cell surface, which prevents contact activation of the intrinsic clotting system; (2) a layer of glycocalyx on the endothelium (glycocalyx is a mucopolysaccharide adsorbed to the surfaces of the endothelial cells),which repels clotting factors and platelets, thereby preventing activation of clotting; and (3) a protein bound with the endothelial membrane, thrombomodulin, which binds thrombin. Not only does the binding of thrombin with thrombomodulin slow the clotting process by removing thrombin, but the thrombomodulin-thrombin complex also activates a plasma protein, protein C, that acts as an anticoagulant by inactivating activated Factors V and VIII. When the endothelial wall is damaged, its smoothness and its glycocalyx-thrombomodulin layer are lost, which activates both Factor XII and the platelets. Antithrombin Action of Fibrin and Antithrombin III. (=antithrombin-heparin cofactor) fibrin helps prevent the spread of thrombin into the remaining blood and, therefore, prevents excessive spread of the clot. The thrombin that does not adsorb to the fibrin fibers soon combines with antithrombin III, which further blocks the effect of the thrombin on the fibrinogen and then also inactivates the thrombin itself. The heparin molecule is a highly negatively charged conjugated polysaccharide. By itself, it has little or no anticoagulant properties, but when it combines with antithrombin III, the effectiveness of antithrombin III for removing thrombin increases by a hundredfold to a thousand fold, and thus it acts as

an anticoagulant and removes XIIa, XIa, Xa, and IXa. Heparin is produced by many different cells of the body, but especially large quantities are formed by the basophilic mast cells located in the pericapillary connective tissue throughout the body (mostly in lungs+liver-slow flow of venous blood) Lysis of Blood Clots-Plasmin (fibrinolysin) Plasminogen (profibrinolysin).Plasmin digests fibrin fibers and some other protein coagulants such as fibrinogen, Factor V, Factor VIII, prothrombin, and Factor XII. When a clot is formed, a large amount of plasminogen is trapped in the clot along with other plasma proteins. This will not become plasmin or cause lysis of the clot until it is activated. The injured tissues and vascular endothelium very slowly release a powerful activator called tissue plasminogen activator (t-PA) that a few days later, after the clot has stopped the bleeding, eventually converts plasminogen to plasmin, which in turn removes the remaining unnecessary blood clot Conditions That Cause Excessive Bleeding in Human Beings Excess bleeding can be caused deficiency of any one of the clotting factors eg bleeding caused by (1) vitamin K deficiency, (2) hemophilia, and (3) thrombocytopenia (platelet deficiency) (1) prothrombin, factor VII, IX, X caused by Vit K defiency. Almost all blood-clotting factors are formed by the liver. Diseases such as hepatitis, cirrhosis depress clotting system. Vitamin K is continually synthesized in the intestinal tract by bacteria, so that vitamin K deficiency seldom occurs in the normal person as a result of vitamin K absence from the diet (except in neonates before they establish their intestinal bacterial flora). Poor absorption of fats from the gastrointestinal tract. The reason is that vitamin K is fat-soluble and ordinarily is absorbed into the blood along with the fats. One of the most prevalent causes of vitamin K deficiency is failure of the liver to secrete bile into the gastrointestinal tract. (2) Hemophilia is a bleeding disease that occurs almost exclusively in males. In 85 per cent of cases, it is caused by an abnormality or deficiency of Factor VIII; this type of hemophilia is called hemophilia A or classic hemophilia. Factor VIII has two active components, a large component and a smaller component. The smaller component is most important in the intrinsic pathway for clotting, and it is deficiency of this part of Factor VIII that causes classic hemophilia. Another bleeding disease with somewhat different characteristics, called von Willebrand s disease, results from loss of the large component. (3) Thrombocytopenia means the presence of very low numbers of platelets in the circulating blood. The skin of such a person displays many small, purplish blotches, giving the disease the name

Euglobulin: one of a class of globulins characterized by being insoluble in water but soluble in saline

thrombocytopenic purpura . Ordinarily, bleeding will not occur until the number of platelets in the blood falls below 50,000/ml, rather than the normal 150,000 to 300,000. Most people with thrombocytopenia have the disease known as idiopathic thrombocytopenia An abnormal clot that develops in a blood vessel is called a thrombus; such freely flowing clots are known as emboli. The causes of thromboembolic conditions in the human being are usually Twofold: (1) Any roughened endothelial surface of a vessel as may be caused by arteriosclerosis, infection, or trauma is likely to initiate the clotting process. (2) Blood often clots when it flows very slowly through blood vessels, where small quantities of thrombin and other procoagulants are always being formed. Use of t-PA in Treating Intravascular Clots Anticoagulants for Clinical Use In some thromboembolic conditions, it is desirable to delay the coagulation process. The ones most useful clinically are heparin (injected herparin is destroyed by heparinase) and the coumarins (warfarin). Plasma levels of prothrombin and Factors VII, IX, and X, all formed by the liver, begin to fall after warfarin administration-warafin competes with Vit K (takes btwn 12-24 hrs to see effects) Various substances that decrease the concentration of calcium ions in the blood can also be used for preventing blood coagulation outside the body.