Dr: Marwa Osman kam shash

The process of haemostasis occurs in three

phases :
1. The vascular platelet phase, which assures
primary haemostasis

2. Activation of the coagulation cascade, which

assures formation of the clot

3. And activation of a series of control mechanisms,

which stop propagation of the clot and limit
activation of the coagulation cascade to the
region of endothelial rupture.
Coagulation Tests
1. Tests of the Vascular Platelet Phase of
Haemostasis:
 Bleeding Time (BT)

2. Tests of the Coagulation Cascade:

 ClottingTime ( CT) or Coagulation time
 Activated Partial Thromboplastin Time (APTT).

 Prothrombin Time (PT).

3. Tests of Fibrinolysis and the Mechanisms

That Control Hemostasis:
 Fibrin Degradation Products (FDP)
Bleeding Time (BT)
Principle:
 The bleeding time test is a useful tool to test for
platelet plug formation and capillary integrity.
Occasionally, the bleeding time test will be
ordered on a patient scheduled for surgery.

 The bleeding time is dependent upon

 Blood vessels function.
 The number of blood platelets present and
their ability to form a platelet plug.
Bleeding Time (BT)
 Prolonged bleeding times are generally
found when
 The platelet count is below 50,000/µL
 When there is platelet dysfunction.

 Three procedures are currently in use for

determining the bleeding time:
 The Duke method.
 The Ivy Method.
 The standerdized template Metehod.
Duke Method
 With the Duke method, the patient is
pricked with a special needle or lancet,
preferably on the earlobe or fingertip,
after having been swabbed with alcohol.
 The prick is about 3–4 mm deep. The
technician then wipes the blood every 30
seconds with a filter paper.
 This test method is the easiest to
perform, but is the least standardized
and has the less precision and accuracy.
Normal Range:
1-3 mins
Ivy Method
 In the Ivy method, a blood pressure cuff is placed
on the upper arm and inflated to 40 mmHg to
control capillary tone and to improve the
sensitivity and reproducibility– this will maintain
constant pressure within the capillaries and help
standardize the procedure- .
 A sterile, disposable blood lancet is used to make
a two separte incision that is 1 millimeter deep on
the underside of the forearm.
 Every 30 seconds, filter paper is used to draw off
the blood.
 The time from when the incision is made until all
bleeding has stopped is measured.
Method

 The test is finished when bleeding has stopped

completely.
 A prolonged bleeding time may be a result from
decreased number of thrombocytes or impaired
blood vessels. However, it should also be noted
that the depth of the puncture or incision may be
the source of error.
 Normal values fall between 2 – 7 minutes
depending on the method used.
 The greatest source of variation in this test is
largely due to difficulty in performing a
standardized puncture. This usually leads to
erroneously low results.
Standardize template Method
 A Modification of the Ivy Method.
 Principle:
 A standerdized incision is made in the surface of
the forearm and the time of incision bleed is
measured.
 Cessation of blood indicate formation of
haemostatic plug which in turn depend on
adequate plts number and function.
Advantages of this method include:
Instrument is a sterile, standardized, easy to
use device that makes a uniform incision.

This method is the most standardized method of

all the bleeding time procedures.

Disadvantages of this method include:

Slight scarring can occur so patient should be
informed.
 Materials:
 Blood pressure cuff
 Template bleeding time device
 Stopwatch
 Whatman No. 1 circular filter
paper
 Alcohol pads
 Gloves
Preparation of the Patient
 After proper greeting and identification of the
patient, explain the test for patient.

 It is critical that you ask the patient whether or

not they have taken aspirin, aspirin containing
compounds (many over the counter medications
contain aspirin) or blood thinners such as heparin
or Coumadin recently. These drugs will cause a
falsely abnormal bleeding time and the test should
not be done.
Procedure:
1. Explain the procedure to the patient.
2. Obtain a history about aspirin or aspirin containing
compounds taken within last 7 - 10 days.
3. Select a site on the patient's forearm approximately
three fingers widths below the bend in the elbow that is
free of visible subcutaneous veins.
4. Cleanse the outer surface of the patient's forearm by
moving the alcohol pad in concentric circles from the
incision site outward; allow to air dry.
5. Place a blood pressure cuff on the patient's arm above
the elbow. Turn the knob on the bulb of the
sphygmomanometer until it stops. Squeeze the bulb to
inflate the sphygmomanometer. Inflate the cuff and
maintain pressure at 40 mm Hg.
re:
7. Take lancet and make incisions and starting stop
watch.
8. .After 30 seconds have passed blot (do not wipe) the
blood with the filter paper. The filter paper must not
touch the wound on the arm. Blot the site at regular
thirty second intervals. Rotate the filter paper after
each 30 seconds.
9. When bleeding ceases and blood no longer is drawn to
the filter paper, stop the watch and release the blood
pressure cuff by turning the knob next to the bulb in
the opposite direction used to inflate the cuff. Remove
the blood pressure cuff.
10.Record the bleeding time. Bleeding time is
determined to the nearest 30 seconds.
re:

12. After ensuring that the bleeding has stopped, carefully

bandage the site.
13. Appropriately discard all used materials and wash hands.

Normal Range:
2.5-9.5 min
Sources of Error
 If the patient has taken aspirin or aspirin-containing
compounds 7 to 10 days prior to the procedure, the
bleeding time may be prolonged. The technician must
determine the patient's history concerning aspirin
ingestion to ensure quality results.
About 20 different medications, including antihistamines and
nonsteroidal anti-inflammatory drugs such as aspirin and
ibuprofen, impair the platelets' ability to stick to wounds, and
therefore produce a longer bleeding time.
 Results may be affected by an improperly performed
puncture. A puncture that is too shallow, too deep, or in
an inappropriate location will adversely affect test results.
 The alcohol must be completely dried before making the
puncture. If residual alcohol is on a puncture site, the
bleeding time will be erroneously prolonged.
Sources of Error
 If the technician does not initiate timing of the
procedure simultaneously with the puncture, the
results will be adversely affected.
 If the technician allows the filter paper to touch the
wound, the platelet clot may be dislodged, causing
falsely elevated results.
 If the stopwatch has not been appropriately
calibrated, it may keep incorrect time. Stopwatches
should be calibrated on a regular basis as a part of
the quality assurance program.
 The direction of the incision should be consistent. A
horizontal incision gives a longer bleeding time than
a vertical incision
 The bleeding time is prolonged in thrombocytopenia,
hereditary and acquired platelet dysfunctions, von
Willebrand's disease, a fibrinogenemia, severe
hypofibrinogenemia, and some vascular bleeding
disorders
Sources of Error
 Errors producing false prolonge results
Blood pressure cuff maintained too high (>40mm
Hg.(
Incision too deep, caused by excessive pressure on
the incision device.
Disturbing the clot with the filter paper.
Low fibrinogen (<100 mg/dl) or platelet count
(100,00 /mm3(
Drug ingestion affecting platelet function (e.g.
Asprin(

 Errors producing false short results

Blood pressure cuff maintained too low (<40 mm Hg)
Incision too shallow.
Next Lecture: Clotting Time