Hemostasis and Blood Transfusion — MCQs

10 questions

All are predisposing factors of Deep Vein thrombosis, EXCEPT :

Hemophilia B is a deficiency of which factor?

Case of trauma in a patient with an unknown blood group. Patient is unstable and requires urgent blood transfusion. Which type of blood should be transfused?

Converging point of both pathways in coagulation is at:

Best blood product to be given in a patient of multiple clotting factor deficiency with active bleeding:

A patient who presented with blunt abdominal injury underwent complete repair of liver and was given transfusion of 12 units of whole blood. Thereafter, it is found that the wound is bleeding. It is treated by

What is the best procedure to control external hemorrhage in an event of accidental injury?

What is the volume threshold that defines a massive blood transfusion?

According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

Q10

Most common immediate complication of splenectomy:

Hemostasis and Blood Transfusion Indian Medical PG Practice Questions and MCQs

Question 1: All are predisposing factors of Deep Vein thrombosis, EXCEPT :

A. Lower limb trauma
B. Cushing's syndrome
C. Hip surgery
D. Subungual melanoma (Correct Answer)

Explanation: ***Subungual melanoma*** - This is a rare form of melanoma that develops under the nail, and while serious, it is **not a recognized predisposing factor for deep vein thrombosis (DVT)**. Its primary concerns are local invasion and metastasis. - Unlike conditions affecting blood clotting or endothelium, **subungual melanoma does not directly promote hypercoagulability, venous stasis, or endothelial damage** that contribute to DVT. *Lower limb trauma* - **Trauma to the lower limb** can cause **endothelial damage** to blood vessels and **venous stasis** due to immobility or swelling, both key components of **Virchow's triad** for DVT [1]. - **Fractures or severe soft tissue injuries** often necessitate immobilization and can lead to inflammation, further increasing the risk of clot formation [1]. *Cushing's syndrome* - **Cushing's syndrome** is associated with **hypercoagulability** due to increased levels of clotting factors, such as **factor VIII** and **fibrinogen**, and decreased fibrinolytic activity. - The **elevated cortisol levels** seen in Cushing's syndrome [2] can directly contribute to a prothrombotic state, significantly increasing DVT risk. *Hip surgery* - **Major orthopedic surgeries**, especially hip surgery [1], are well-known to cause significant **venous stasis** and **endothelial damage**. - **Post-operative immobility** and a generalized **inflammatory response** following surgery contribute to a high risk of DVT formation [1].

Question 2: Hemophilia B is a deficiency of which factor?

A. IX (Correct Answer)
B. XII
C. VIII
D. X

Explanation: ***IX*** - Hemophilia B, also known as **Christmas disease**, is caused by a deficiency in **Factor IX** [1]. - This condition is an **X-linked recessive disorder** that impairs the blood's ability to form clots, leading to prolonged bleeding [1]. *XII* - Deficiency in **Factor XII** (Hageman factor) is usually **asymptomatic** and does not lead to a bleeding disorder. - Individuals with Factor XII deficiency often have a **prolonged aPTT** but no clinical bleeding. *VIII* - A deficiency in **Factor VIII** causes **Hemophilia A**, which is the more common form of hemophilia [1]. - Hemophilia A also presents with bleeding symptoms, but it is distinct from Hemophilia B due to the specific factor involved [1]. *X* - Deficiency in **Factor X** (Stuart-Prower factor) is a rare **autosomal recessive** bleeding disorder. - Factor X deficiency affects both the intrinsic and extrinsic coagulation pathways, leading to prolongation of both **PT and aPTT**.

Question 3: Case of trauma in a patient with an unknown blood group. Patient is unstable and requires urgent blood transfusion. Which type of blood should be transfused?

A. O- (Correct Answer)
B. AB+
C. O+
D. A+

Explanation: ***O-*** - **O-negative blood** is considered the **universal donor** because it lacks A, B, and Rh (D) antigens, making it safe for transfusion to patients of any blood type in an emergency. - In a critically unstable patient with an unknown blood group requiring urgent transfusion, using **O-negative blood minimizes the risk of a severe acute hemolytic transfusion reaction**. *AB+* - **AB-positive blood** is the **universal recipient** blood type, meaning individuals with AB+ blood can receive blood from any donor. - However, transfusing AB+ blood to a patient with an unknown blood type could lead to a **severe hemolytic reaction** if the patient is not AB+. *O+* - While **O-positive blood** is common and can be given to individuals who are Rh-positive, it contains the **Rh antigen**. - Transfusing O-positive blood to an Rh-negative patient (whose Rh status is unknown in this emergency) could cause **alloimmunization** and a hemolytic reaction. *A+* - **A-positive blood** contains A antigens and Rh antigens. - Giving A-positive blood to a patient with an unknown blood type is risky, as it would cause a **hemolytic reaction** if the patient is B, AB, or O, or if they are Rh-negative.

Question 4: Converging point of both pathways in coagulation is at:

A. Factor VIII
B. Stuart factor X (Correct Answer)
C. Factor IX
D. Factor VII

Explanation: ***Stuart factor X*** [1][2] - It is the main **converging point** of the coagulation cascade, where both the intrinsic and extrinsic pathways meet to initiate the common pathway [1]. - Activated factor X leads to the conversion of **prothrombin to thrombin**, pivotal for clot formation [2]. *Factor VII* [2] - Primarily involved in the **extrinsic pathway** of coagulation, activating factor X, but does not serve as a converging point. - Its function is limited to starting the coagulation cascade, particularly upon tissue injury. *Factor IX* [2] - A key component of the **intrinsic pathway**, it leads to the activation of factor X but is not the point where both pathways converge. - It requires **factor VIII** for its activation, further illustrating its role within a specific pathway. *Factor VIII* - Also part of the **intrinsic pathway**, it acts as a cofactor for factor IX but does not integrate both pathways into a common point. - Its deficiency is associated with **Hemophilia A**, underscoring its specific pathway involvement. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, pp. 128-130. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 582-583.

Question 5: Best blood product to be given in a patient of multiple clotting factor deficiency with active bleeding:

A. Whole blood
B. Packed RBCs
C. Cryoprecipitate
D. Fresh frozen plasma (Correct Answer)

Explanation: ***Fresh frozen plasma*** - **Fresh frozen plasma (FFP)** contains all coagulation factors, including labile factors V and VIII, making it the best choice for patients with multiple clotting factor deficiencies and active bleeding. - It rapidly replenishes clotting factors, which is critical in scenarios of **acute hemorrhage** due to global coagulopathy. *Whole blood* - **Whole blood** contains red blood cells, plasma, and platelets, but its clotting factor concentration is lower than FFP and deteriorates over storage. - It is preferred for massive hemorrhage with significant blood volume loss, but less effective for isolated clotting factor deficiencies without substantial volume depletion. *Packed RBCs* - **Packed red blood cells (PRBCs)** are primarily used to increase oxygen-carrying capacity by raising hemoglobin levels in anemic patients. - They lack significant amounts of clotting factors and are therefore not effective in treating active bleeding due to coagulation factor deficiencies. *Cryoprecipitate* - **Cryoprecipitate** contains specific clotting factors, namely factor VIII, von Willebrand factor, fibrinogen, and factor XIII. - While useful for deficiencies in these specific factors (e.g., hemophilia A, DIC with low fibrinogen), it does not provide a broad spectrum of all clotting factors needed for general multiple factor deficiencies.

Question 6: A patient who presented with blunt abdominal injury underwent complete repair of liver and was given transfusion of 12 units of whole blood. Thereafter, it is found that the wound is bleeding. It is treated by

A. Vitamin-K
B. Platelet concentrates (Correct Answer)
C. Calcium gluconate/calcium chloride
D. Fresh Frozen Plasma

Explanation: ***Platelet concentrates*** - Transfusion of **large volumes of whole blood** can lead to **dilutional coagulopathy**, primarily affecting platelet count and function. - The most effective immediate treatment for bleeding due to dilutional coagulopathy after massive transfusion is the administration of **platelet concentrates** to replenish platelet levels. *Vitamin-K* - **Vitamin-K** is essential for the synthesis of **coagulation factors II, VII, IX, and X** in the liver. - Its administration is typically indicated for patients with **warfarin overdose** or **liver dysfunction**, neither of which is the primary cause of bleeding in this scenario. *Calcium gluconate/calcium chloride* - **Calcium** is an important cofactor in several steps of the coagulation cascade. - While citrate in transfused blood can chelate calcium, significant **symptomatic hypocalcemia** affecting coagulation is less common and usually does not manifest as persistent surgical site bleeding. *Fresh Frozen Plasma* - **Fresh Frozen Plasma (FFP)** provides a broad spectrum of **coagulation factors**, addressing deficiencies in clotting factors. - While FFP can be helpful in massive transfusion protocols, the primary issue after 12 units of whole blood is often **dilutional thrombocytopenia**, making platelet concentrates a more direct and effective initial treatment for sustained bleeding.

Question 7: What is the best procedure to control external hemorrhage in an event of accidental injury?

A. Proximal tourniquet
B. Artery forceps
C. Elevation
D. Direct pressure (Correct Answer)

Explanation: ***Direct pressure*** - **Direct pressure** is the most immediate and effective first-aid measure for controlling external bleeding by compressing the injured vessel. - Applying firm, direct pressure with a clean cloth or hand helps to promote **hemostasis** and allow for clot formation at the site of injury. *Proximal tourniquet* - A **tourniquet** is a last resort for severe, life-threatening hemorrhage that cannot be controlled by direct pressure, as it can cause **tissue damage** and ischemia. - It should be applied proximal to the injury, but its prolonged use carries risks of **nerve damage** and limb loss. *Artery forceps* - **Artery forceps** are surgical instruments used to clamp individual blood vessels during a surgical procedure, not for initial control of external hemorrhage in an emergency. - Their use requires expertise and carries risks of further injury if not applied correctly by trained medical personnel. *Elevation* - **Elevation** of the injured limb above the level of the heart can help reduce blood flow and venous pressure, which may aid in controlling minor bleeding. - However, elevation alone is usually insufficient for significant hemorrhage and should be used in conjunction with **direct pressure**.

Question 8: What is the volume threshold that defines a massive blood transfusion?

A. Transfusion of 1 unit every 30 minutes for 6 hours.
B. Transfusion of 5 units in 12 hours.
C. More than 10 units in 24 hours. (Correct Answer)
D. Transfusion of 8 units in 24 hours.

Explanation: ***More than 10 units in 24 hours.*** - This is the **most widely accepted and standard definition** for a massive blood transfusion used in clinical practice and medical literature. - This threshold indicates that a patient has received a volume of blood products roughly equivalent to their **total blood volume** within a 24-hour period. - This definition is used to trigger **massive transfusion protocols (MTP)** in trauma and critical care settings. *Transfusion of 1 unit every 30 minutes for 6 hours.* - This scenario would result in 12 units over 6 hours, which does represent a massive transfusion situation clinically. However, the **standard textbook definition** refers to the total unit threshold over a 24-hour period, not a rate-based criterion. - While this rate of transfusion is critical and would trigger massive transfusion protocols, the question asks for the **volume threshold definition**, which is standardly stated as ≥10 units in 24 hours. *Transfusion of 5 units in 12 hours.* - This volume of transfusion is considered a **moderate to large transfusion**, not meeting the criteria for a massive blood transfusion. - While substantial and requiring close monitoring, it does not reach the commonly accepted threshold of 10 or more units within 24 hours. *Transfusion of 8 units in 24 hours.* - This amount is significant but falls short of the conventional definition of a **massive blood transfusion**, which requires 10 or more units in 24 hours. - While requiring aggressive management and monitoring, it doesn't meet the standard diagnostic threshold for massive transfusion.

Question 9: According to ATLS classification of hemorrhagic shock, a patient with decreased blood pressure, decreased urine output and decreased circulatory volume of 30-40% is managed by?

A. blood transfusion alone
B. crystalloids infusion
C. crystalloids+blood transfusion (Correct Answer)
D. plasma therapy

Explanation: ***Correct: crystalloids+blood transfusion*** - A 30-40% blood volume loss, indicated by **decreased blood pressure** and **decreased urine output**, corresponds to ATLS **Class III hemorrhagic shock**. - Management for Class III shock requires both **intravenous crystalloids** to restore circulatory volume and **blood transfusion** to replace lost red blood cells and improve oxygen-carrying capacity. - The initial approach follows the **3:1 crystalloid replacement rule**, followed by or concurrent with **packed red blood cells** to address ongoing hemorrhage and maintain oxygen delivery. *Incorrect: blood transfusion alone* - While blood transfusion is crucial for Class III hemorrhagic shock, administering it **alone** without initial crystalloid resuscitation may not adequately address the immediate need for **intravascular volume expansion**. - **Crystalloids** are typically administered first or concurrently to rapidly restore circulating volume and support perfusion before packed red blood cells can be prepared and transfused. *Incorrect: crystalloids infusion* - **Crystalloids alone** would be insufficient for Class III hemorrhage as the patient has experienced significant **red blood cell loss** (30-40% circulating volume) which requires direct replacement to improve oxygen delivery. - While initial crystalloid resuscitation is vital, continuing with crystalloids alone will lead to **dilutional coagulopathy** and failure to correct oxygen-carrying capacity. *Incorrect: plasma therapy* - **Plasma therapy** (e.g., fresh frozen plasma) is primarily used for the correction of **coagulopathy** in actively bleeding patients or those with anticipated massive transfusion. - Although it may be part of a massive transfusion protocol for severe hemorrhage, it is not the primary or sole initial treatment strategy for volume resuscitation and red blood cell replacement in Class III shock.

Question 10: Most common immediate complication of splenectomy:

A. Bleeding from gastric mucosa
B. Fistula
C. Hemorrhage (Correct Answer)
D. Pancreatitis

Explanation: ***Hemorrhage*** - **Hemorrhage** is the most common immediate complication due to the **highly vascular nature** of the spleen and the potential for inadequate ligation of splenic vessels. - This can lead to significant **blood loss** requiring further intervention or transfusion. *Bleeding from gastric mucosa* - While stress ulcers or gastritis can occur post-operatively, **gastric mucosal bleeding** is not the most common immediate complication directly related to splenectomy. - This is a less direct complication compared to issues with the surgical site itself. *Fistula* - **Fistula formation**, such as a pancreatic fistula, can occur after splenectomy, but it is typically a less common immediate complication than hemorrhage. - The development of a fistula usually takes some time to manifest fully or requires specific damage to adjacent organs. *Pancreatitis* - **Pancreatitis** can occur due to accidental trauma to the tail of the pancreas, which lies in close proximity to the splenic hilum during surgery. - While a serious complication, it is not as frequent as hemorrhage as an immediate post-operative concern.

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