Coagulation (secondary hemostasis)

Hemostasis can be broken down into hemo referring to blood or bleeding and stasis meaning to stop - so together it means stopping bleeding. Hemostasis has two phases: primary and secondary hemostasis.

In primary hemostasis, platelets aggregate to form a plug at the site of an injured blood vessel. While these platelets are aggregating, coagulation, or secondary hemostasis starts.

This is where numerous enzymes that are always floating around in the blood called clotting factors get proteolytically activated, meaning that activation happens when a small piece is chopped off - a bit like pulling the pin out of a grenade.

These factors activate one another, eventually leading to the activation of fibrin or factor Ia. That results in a fibrin mesh which forms around the platelet plug to reinforce it and hold it together.

Without primary and secondary hemostasis, our body would suffer massive blood loss from even the most minor injuries--imagine losing all of your blood volume from something as simple as a pinprick!

So let’s get into the details of secondary hemostasis. The process of forming the fibrin mesh begins via two pathways --the extrinsic and intrinsic pathways.

The intrinsic pathway is called intrinsic because all of the factors required to activate it are intrinsic, or found within the blood.

Conversely, the extrinsic pathway is called extrinsic because it’s activated by tissue factor found extrinsically, or outside of the blood.

Both pathways can become activated independently and ultimately culminate in the activation of factor X, which then proceeds to activate the rest of the coagulation cascade via the common pathway.

Let's start with the extrinsic pathway. It starts when trauma damages the blood vessel, and exposes the cells under the endothelial layer, like smooth muscle cells, which have tissue factor or factor III in their membrane.