CTBT

Bleeding time,clotting time,
PT, and PTT
Dr. Ayham Abu Laila
Hemostasis or
haemostasis
Is
a complex process which causes

the bleeding process to stop.
It refers to the process of keeping
blood within a damaged blood
vessel.
Hemostasis is maintained in the

body via three mechanisms:
Vascular
spasm - Damaged blood vessels
constrict.
Platelet plug formation - Platelets
adhere to damaged endothelium to form
platelet plug (primary hemostasis) and
then degranulate.
Blood coagulation - Clots form upon the
conversion of fibrinogen to fibrin, and its
addition to the platelet plug (secondary
hemostasis).
THE CLOTTING MECHANISM

INTRINSIC
Collagen
EXTRINSC
Tisue Thromboplastin
XII
XI
IX
VIII
VII
X
FIBRINOGEN
(I)
V
PROTHROMBIN
(II)
THROMBIN
(III)
FIBRIN
FIBRINOLYTIC PHASE
ANTICLOTTING
MECHANISMS ARE
ACTIVATED TO ALLOW CLOT
DISINTEGRATION AND REPAIR OF THE
DAMAGED VESSEL.
HEMOSTASIS
DEPENDENT
UPON:
Vessel Wall Integrity

Adequate Numbers of Platelets
Proper Functioning Platelets
Adequate Levels of Clotting Factors
Proper Function of Fibrinolytic Pathway
So What Causes Bleeding

Disorders?
VESSEL DEFECTS
PLATELET DISORDERS
FACTOR DEFICIENCIES
VESSEL DEFECTS
VITAMIN C DEFICIENCY
BACTERIAL & VIRAL INFECTIONS
ACQUIRED
PLATELET DISORDERS
THROMBOCYTOPENIA
(INADEQUATE NUMBER OF PLATELETS)
Causes
DRUG INDUCED
BONE MARROW FAILURE
HYPERSPLENISM
OTHER CAUSES
THROMBOCYTOPATHY
)ADEQUATE NUMBER BUT ABNORMAL
FUNCTION .(
causes
UREMIA
INHERITED DISORDERS
MYELOPROLIFERATIVE DISORDERS
DRUG INDUCED(ASPIRIN,
NSAIDS)
FACTOR DEFICIENCIES
Inherited:
1.
HEMOPHILIA A
2.
HEMOPHILIA B
3.
VON WILLEBRANDS
DISEASE
Acquired:
1.
Anticoagulant
therapy
2.
Liver diseases
3.
DIC
LABORATORY EVALUATION
PLATELET
COUNT
BLEEDING TIME (BT)
Clotting time (CT)
PROTHROMBIN TIME (PT)
Activated PARTIAL THROMBOPLASTIN
TIME (APTT)
PLATELET COUNT (CBC)

NORMAL
100,000 - 400,000
CELLS/MM3
Thrombocytopenia
100,000>
Mild Thrombocytopenia100,000 - 50,000

Sever Thrombocytopenia 50,000>
BLEEDING TIME
PROVIDES ASSESSMENT OF
PLATELET COUNT AND FUNCTION
NORMAL VALUE
2-8 MINUTES
Clotting time - capillary method
Material
1.
Sterile disposable pricking needle or lancet.

Stop watch
Dry glass capillary tube (narrow diameter 1 top 2 mm,
minimum 10 cm long.)
Cotton Swab of absorbent cotton.
Spirit wetted, cotton swab.
70 % v/v ethyl alcohol
2.
3.
4.
5.
6.
Clotting time of whole blood
Clotting Time - Slide Method
The surface of the glass tube

initiates the clotting process.
This test is sensitive to the
factors involved in the intrinsic
pathway
The expected range for clotting
time is 4-10 min.
PROTHROMBIN TIME
Measures Effectiveness of the Extrinsic
Pathway
NORMAL VALUE
10-15 SECS
PT
The prothrombin time: is therefore the time required for the plasma
to clot after an excess of thromboplastin and an optimal
concentration of calcium have been added.
Measures the function of the Extrinsic Pathway.
Sensitive to Factors I, II, V, VII, X.
The PT evaluates patients suspected of having an inherited or

acquired deficiency in these pathways.

INTRINSIC
Collagen
EXTRINSC
XII
XI
IX
VIII
VII
X
FIBRINOGEN
(I)
V
PROTHROMBIN
(II)
THROMBIN
(III)
FIBRIN
?When is it ordered
Used to monitor oral anticoagulant therapy (Warfarin /

Coumadin).
When a patient who is not taking anti-coagulant drugs

has signs or symptoms of a bleeding disorder.
When a patient is to undergo an invasive medical

procedure, such as surgery, to ensure normal clotting
ability.
An elevated prothrombin time may

:indicate the presence of
Vitamin K deficiency
(Vitamin K is needed to make prothrombin and other clotting factors )
DIC
liver disease
a deficiency in one or more of the following factors:
I, II, V, VII, X.
Anticoagulant (warfarin)
INR
A PT test may also be called an INR test.

INR (international normalized ratio) stands for a way of
standardizing the results of prothrombin time tests, no
matter the testing method.
So your doctor can understand results in the same way
even when they come from different labs and different
test methods.
Using the INR system, treatment with (anticoagulant
therapy) will be the same. In some labs, only the INR is
reported and the PT is not reported
An INR of 1.0 means that the patient PT is normal.

An INR greater than 1.0 means the clotting time is
elevated.
INR of greater than 5 or 5.5 = unacceptable high risk of
bleeding,whereas if the INR=0.5 then there is a high
chance of having a clot.
Normal range for a healthy person is 0.91.3, and for
people on warfarin therapy, 2.03.0, although the target
INR may be higher in particular situations, such as for
those with a mechanical heart valve.
PARTIAL THROMBOPLASTIN TIME
Measures Effectiveness of the Intrinsic

Pathway
NORMAL VALUE
25-40 SECS
PTT
The partial thromboplastin time (PTT) or activated partial

thromboplastin time (aPTT or APTT( is a performance
indicator measuring the efficacy of both the "intrinsic"
and the common coagulation pathways.
It is also used to monitor the treatment effects with

heparin a major anticoagulant.
Kaolin cephalin clotting time (KccT) is a historic name for

the activated partial thromboplastin time

INTRINSIC
Collagen
EXTRINSC
XII
XI
IX
VIII
VII
X
FIBRINOGEN
(I)
V
PROTHROMBIN
(II)
THROMBIN
(III)
FIBRIN
Normal
PTT times require the

presence of the following coagulation
factors:
I, II, III, IV, V, VI, VIII, IX, X, XI, & XII
?When is it ordered
When a patient presents with unexplained bleeding or

bruising,
It may be ordered as part of a pre-surgical evaluation for

bleeding tendencies,
When a patient is on intravenous (IV) or injection heparin

therapy, the APTT is ordered at regular intervals to
monitor the degree of anticoagulation.
Prolonged APTT may indicate:
use of heparin.
antiphospholipid antibody:especially lupus anticoagulant,

which paradoxically increases propensity to thrombosis
coagulation factor deficiency ,
e.g hemophilia
DIC
Liver disease

INTRINSIC
Collagen
EXTRINSC
XII
XI
IX
VIII
VII
X
FIBRINOGEN
(I)
V
PROTHROMBIN
(II)
THROMBIN
(III)
FIBRIN
FACTOR DEFICIENCIES
Inherited:
1.
Acquired:
1.
Anticoagulant
therapy
2.
Liver diseases
3.
DIC
HEMOPHILIA A
2.
HEMOPHILIA B
3.
VON
WILLEBRANDS
DISEASE
HEMOPHILIA A (Classic Hemophilia)

80-85% of all Hemophiliacs
Deficiency of Factor VIII
Lab Results - Prolonged PTT
HEMOPHILIA
10-15%
B (Christmas Disease)
of all Hemophiliacs
Deficiency of Factor IX
Lab Test - Prolonged PTT
VON
WILLEBRANDS DISEASE
Deficiency
of VWF & amount of Factor VIII

Factor VIII is bound to vWF while inactive in
circulation; Factor VIII degrades rapidly when
not bound to vWF
Lab Results - Prolonged BT, PTT
ANTICOAGULANTS
An anticoagulant is a substance that prevents

coagulation; that is, it stops blood from clotting
This prevents deep vein thrombosis, pulmonar
embolism, myocardial infarction and stroke.
1.
2.
ANTICOAGULANTS
Coumadins (Vitamin K antagonists)

Heparin
Coumadins
These oral anticoagulants that antagonize the

effects of vitamin K .
Examples include warfarin. It takes at least 48 to
72 hours for the anticoagulant effect to develop.
Where an immediate effect is required, heparin
must be given concomitantly.
Monitored by PT times
These anticoagulants are used to treat patients
with deep-vein thrombosis (DVT),
pulmonary embolism (PE), atrial fibrillation (AF),
and mechanical prosthetic heart valves .
Heparin
Heparin is a biological substance.

It works by activating antithrombin III, which
blocks thrombin from clotting blood.
Heparin Therapy is Monitored by PTT times
Low molecular weight heparin is a more highly
processed product that is useful as it does not
require monitoring of the APTT coagulation
parameter (it has more predictable plasma levels)
and has fewer side effects.
Liver Disease
Liver Disease can Result in Reduced

Production of Coagulation
Factors
(I,II,V,VII,IX,X).
DIC
Disseminated intravascular coagulation (DIC is a

pathological activation of coagulation) blood
clotting) mechanisms that happens in response to
a variety of diseases
DIC leads to the formation of small blood clots
inside the blood vessels throughout the body
The small clots also disrupt normal blood flow to
organs (such as the kidneys), which may
malfunction as a result
As the small clots consume coagulation proteins

and platelets, normal coagulation is disrupted and
abnormal bleeding occurs from the skin the
gastrointestinal tract, the respiratory tract and
surgical wounds.
The PT and APTT are usually very prolonged and

the fibrinogen level markedly reduced
High levels of fibrin degradation products,
including D-dimer, are found owing to the intense
fibrinolytic activity stimulated by the presence of
fibrin in the circulation.
Definitive diagnosis depends on the result of

DIC:
Thrombocytopenia) prolonged bleeding time)

Prolongation of prothrombin time and activated
partial thromboplastin time
A low fibrinogen concentration
Increased levels of fibrin degradation products
Condition
Prothrombi
n
time
Partial
thromboplastin
time
Bleeding
time
Platelet
count
Von Willebrand disease
unaffected
prolonged
prolonged
unaffected
Vitamin K deficiency or
Warfarin
prolonged
prolonged
unaffected unaffected
Uremia
unaffected
unaffected
prolonged
Haemophilia
unaffected
prolonged
Factor V deficiency
prolonged
prolonged
Aspirin
unaffected
unaffected
prolonged
unaffected
Thrombocytopenia
unaffected
unaffected
prolonged
decreased
End-stage Liver failure
prolonged
prolonged
prolonged
decreased
Disseminated intravascular
coagulation
prolonged
prolonged
prolonged
decreased
Bernard-Soulier syndrome
unaffected
unaffected
prolonged
decreased
unaffected
THANK YOU

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Bleeding time,clotting time,

PT, and PTT

Dr. Ayham Abu Laila

a complex process which causes

Hemostasis is maintained in the

spasm - Damaged blood vessels

THE CLOTTING MECHANISM

Vessel Wall Integrity

So What Causes Bleeding

PLATELET COUNT (CBC)

Mild Thrombocytopenia100,000 - 50,000

PLATELET COUNT AND FUNCTION

Clotting time - capillary method

Sterile disposable pricking needle or lancet.

Clotting time of whole blood

Clotting Time - Slide Method

The surface of the glass tube

Measures the function of the Extrinsic Pathway.

Sensitive to Factors I, II, V, VII, X.

The PT evaluates patients suspected of having an inherited or

THE CLOTTING MECHANISM

Used to monitor oral anticoagulant therapy (Warfarin /

When a patient who is not taking anti-coagulant drugs

When a patient is to undergo an invasive medical

An elevated prothrombin time may

(Vitamin K is needed to make prothrombin and other clotting factors )

A PT test may also be called an INR test.

An INR of 1.0 means that the patient PT is normal.

PARTIAL THROMBOPLASTIN TIME

Measures Effectiveness of the Intrinsic

The partial thromboplastin time (PTT) or activated partial

It is also used to monitor the treatment effects with

Kaolin cephalin clotting time (KccT) is a historic name for

THE CLOTTING MECHANISM

PTT times require the

When a patient presents with unexplained bleeding or

It may be ordered as part of a pre-surgical evaluation for

When a patient is on intravenous (IV) or injection heparin

Prolonged APTT may indicate:

antiphospholipid antibody:especially lupus anticoagulant,

coagulation factor deficiency ,

THE CLOTTING MECHANISM

HEMOPHILIA A (Classic Hemophilia)

of VWF & amount of Factor VIII

An anticoagulant is a substance that prevents

Coumadins (Vitamin K antagonists)

These oral anticoagulants that antagonize the

Heparin is a biological substance.

Liver Disease can Result in Reduced

Disseminated intravascular coagulation (DIC is a

As the small clots consume coagulation proteins

The PT and APTT are usually very prolonged and

Definitive diagnosis depends on the result of

Thrombocytopenia) prolonged bleeding time)

Von Willebrand disease

End-stage Liver failure

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