1. Anticoagulation in the Acute Care Population Aimee Ring PT, DPT, GCS

2. Coagulation Cascade How a clot forms in the body 3 Pathways Intrinsic Pathway (Factor 12,11 and 9) Extrinsic Pathway (Factor 7 and 10) Common Pathway (Factor 2 and 13) Factor = protein Protease = proteolytic enzyme that breakdowns protein into smaller polypeptides or amino acids *activates factor

3. Intrinsic Pathway coagulation proteins (Factors) circulate in inactive form in the blood Endothelium is devoid of thrombogenic tissue factor and collagen Brisk blood flow removes any activated proteins Factor 12 (inactive) 12a Factor 11 (inactive) 11a Factor 9 (inactive) 9a Factor 8 (von Wiilebrand Factor) activates to 8a Factor 9a and 8a will activate Factor 10 which is the first factor in Common Pathway

4. Extrinsic Pathway Trauma needs to occur to the blood vessel to activate tissue factor tissue factor Factor 7 7a Factor 1010a

5. Common Pathway 10a activated by 9a and 8a (intrinsic) or 7a and tissues factor (extrinsic) Factor 22a prothrombin thrombin 2a converts fibrinogen to fibrin (monomer) Factor 13 13a(causes monomers to mesh) Fibrin Clot

6. Cascade Factor 12 12a Factor 11 11a Factor 9 9a Factor 8 (von Wiilebrand Factor) activates to 8a tissue factor Factor 7 7a Factor 10 10a 10a Factor 2 2a prothrombin thrombin 2a converts fibrinogen to fibrin (monomer) Factor 13 13a (causes monomers to mesh) Fibrin Clot

7. Fibrinolytic  Breakdown fibrin clot by converting plasminogen to plasmin  “clot buster”  tPA  Urokinase  Streptokinase

8. Anticoagulation Prevents fibrin clot from forming by inhibiting activation of Factors within the Coagulation Cascade  Coumarins  Heparin  Direct Factor 10 Inhibitors  Direct Factor 2 Inhibitors

9. Common Uses for Anticoagulation in Acute Care  Prevention of blood clot /pulmonary embolism formation  Atrial Fibrillation (valvular and non-valvular)  Post Orthopedic Surgery (THR, TKR)  Treatment of blood clot/pulmonary embolism  Stroke

10. Coumadin (Warfarin)  Inhibits Vitamin K in synthesis of factors in Cascade  Inhibits Factors 10, 9, 7 and 2  Therapeutic INR 2.0-3.0  Blood draws  Bridging with Lovenox

11. Inhibitors  Direct Factor 2 inhibitor  Pradaxa (Dabigatran)  Direct Factor 10 inhibitor  Arixtra (Fondaparinux)  Xarelto (Rivaroxaben)  Eliquis (Apixaban)  Lovenox (Enoxaparin) LMWH

12. Testing  PT and PTT - Test together to figure out bleeding or clotting disorder  Prothrombin Time (Factor 1, 2, 5, 7, 9, 10, 11)  Intrinsic Pathway  Partial Thromboplasmin Time (Factor 1, 2, 5, 7, 10)  Extrinsic Pathway

13. INR  International Normalised Ratio  how long it takes the blood to clot  INR = (prothrombin test / prothrombin control ) isi  The ISI is a numerical value representing the responsiveness of any given commercial system relative to the international standard.

14. Physical Therapy Intervention  Precautions  Early Identification of a medical emergency  HITHeparin Induced Thrombocytopenia  Type 2  Life threatening  may manifest as skin lesions at heparin injection sites  acute systemic reactions (chills, fever, dyspnea, chest pain)

15. Precautions Continued  Dosing and therapeutic levels  Bleeding – main side effect of anticoagulants  Ability to reverse anticoagulation effects

16. Benefits of Mobility  Early mobilization and prevention of blood clots  Mobilization with the presence of blood clot and pulmonary embolism