Hematologic Emergencies Flashcards
the ability of the body to control bleeding and clotting
4 major actions involved in achieving hemostasis
Local vasoconstriction to reduce blood flow.
Platelet aggregation at the injury site and formation of a platelet plug.
Formation of a fibrin mesh to strengthen the plug.
Dissolution of the clot after tissue repair is complete.
NOT NEED TO KNOW 4 major actions
Hemostasis:
Affect body’s ability control bleeding, clotting or both
DIC: Disseminated intravascular coagulation
a platelet count less than 150,000/mm3 or a decrease of greater than 50% from the last measurement.
Lab values in DIC and HIT
Thrombocytopenia:
Affect body’s ability control bleeding, clotting or both
HIT: Heparin-induced thrombocytopenia
Aka Consumptive coagulopathy - continuous process of trying to heal damaged endothelium depletes the clotting factors, RBCs, platelets
Characterized by bleeding and thrombosis
Causes
Description - Disseminated intravascular coagulation (DIC)
Obstetric Complications
Infections
Neoplasms
Massive Tissue Injury
Miscellaneous
Causes
Abruptio placentae
Placenta previa
Retained dead fetus
Septic abortion
Amniotic fluid embolism
Toxemia of pregnancy
Obstetric Complications
Gram-negative sepsis
Gram-positive sepsis
Meningococcemia
Rocky Mountain spotted fever
Histoplasmosis
Aspergillosis
Malaria
Infections
Carcinomas of pancreas, prostate, lung, and stomach
Acute promyelocytic leukemia
Tumor lysis syndrome
Chemotherapy
Neoplasms
Trauma
Crush injuries
Burns
Extensive surgery
Heat stroke
Acute transplant rejection
Massive Tissue Injury
Acute intravascular hemolysis
Snakebite
Giant hemangioma
Shock
Heat stroke
Vasculitis
Aortic aneurysm
Liver disease
Cardiac arrest
Miscellaneous
Damage to the endothelium that results in activation of the coagulation mechanism
Caused by damage to endothelium - most common causes: sepsis, trauma, metabolic acidosis, hypoperfusion, OB emergencies
Pathophysiology - Disseminated intravascular coagulation (DIC)
CM
Laboratory findings
Medical management
Nursing management
Assessment and dx - Disseminated intravascular coagulation (DIC)
Integumentary
Cardiopulmonary
Renal
Gastrointestinal
Neurologic
Clotting and bleeding at same time
Excessive clotting (thrombi)
Excessive bleeding
CM
Signs r/t hemorrhage: Bleeding from gums, venipunctures, and old surgical sites; epistaxis; eccymoses
Signs r/t thrombi: peripheral cyanosis, gangrene
Integumentary
Signs r/t hemorrhage: hemoptysis
Signs r/t thrombi: dysrhythmias, chest pain, acute MI, PE, respiratory failure
Cardiopulmonary
Signs r/t hemorrhage: hematuria
Signs r/t thrombi: oliguria, AKI
Renal
Signs r/t hemorrhage: abdominal distention, hemorrhage
Signs r/t thrombi: diarrhea, constipation, bowel infarct
Gastrointestinal
Signs r/t hemorrhage: subarachnoid hemorrhage
Signs r/t thrombi: altered LOC, ischemic stroke
Neurologic
Due to body trying to heal endothelium which eventually disrupts hemostasis process
Thrombus continuously formed on endothelial wall until big enough to occlude blood vessel
Thrombi (blood clots) in peripheral capillaries
Smaller blood vessels occlude first - Occlude distal arteries causing cyanosis (fingers, toes, ears, nose). And smaller vessels in organs
Occlude blood flow to organs → Organ ischemia → Organ failure
Depletes of clotting factors, platelets, and RBCs
Excessive clotting (thrombi)
Clotting factors depleted to continuous activation of coag pathways
Because clotting factors depleted not any left in body when needs to form a clot
Subtle signs: oozing around IV site, blood nose, bruise easier
Bleeding around IVs, ecchymosis
Excessive bleeding
After determine pt has CM of bleeding and thrombus - look at lab values
Studies in DIC
1. look at platelets - DIC first see 50% drop in platelets or platelet count <50,000
2. D-dimer, aPTT, fibrinogen levels
In addition to labs associated with coag pathways - assess end organ perfusion
Continuous activation of coagulation pathways → consumption of coagulation factors
Increased fibrinolytic activity
Impaired regulatory function - ↓levels of inhibitory factors such as protein C, factor V, and End-organ failure
Laboratory findings
Prothrombin time (PT)
>12.5 s
Platelets
<50,000/mm3 or at least 50% drop from baseline
Activated partial thromboplastin time (aPTT)
>40 s
D-dimer
>250 ng/mL
Fibrin degradation products (FDP)
>40 mg/mL
Fibrinogen
<100 mg/dL
Studies in DIC
↑ activated partial thromboplastin time (PTT), ↑ prothrombin time (PT), and ↑ international normalized ratio (INR), ↓Fibrinogen levels
The platelet count may be within normal ranges - Declining trend in values.
Unexpected drop of at least 50% in the platelet count.
Continuous activation of coagulation pathways → consumption of coagulation factors
↑ fibrinolytic activity increases the levels of by-products
D-Dimers - result only from dissolution of clots.
Increased fibrinolytic activity
Kidney→ BUN & Creat. - elevated: poor perfusion to kidneys due to thrombosis occluding blood flow in organ
Liver→ LFTs - elevated: poor perfusion to kidneys due to thrombosis occluding blood flow in organ
Lungs →assess Respiratory effort, ABG’s (acute resp acidosis) = thrombosis in pulm vasculature have shortness of air that progresses to pulmonary failure; ABGs correlate
Brain → Neuro changes: CT to rule out thrombi in brain
Impaired regulatory function - ↓levels of inhibitory factors such as protein C, factor V, and End-organ failure
Focused on Prevention - not prevent most causes - better outcomes if identify going into DIC early
Maintain organ perfusion/Prevent end-organ ischemia/damage
Slowing consumption of coagulation factors – Heparin
Medical management
Support BP - + Inotropes - also want orders that will help circulate volume
Euvolemia - also want orders that will help circulate volume
Continuous IV fluids
RBC’s low due to hemorrhage - packed cell
Maintaining adequate BP and adequate evolumenia promotes adequate blood flow to the organs
Platelet transfusion: Platelet depletion (less than 50,000/mm3)
Cryoprecipitate: Fibrinogen levels less than 100 mg/dL
Fresh frozen plasma: Prolonged prothrombin time
Maintain organ perfusion/Prevent end-organ ischemia/damage
Determine by lab values
Infuse platelets if platelet value <50000
Cryo if fibrinogen <100
FFP protime prolonged
Beneficial in obstetric emergencies such as retained placenta or incomplete abortion, severe arterial occlusions, or MODS caused by microemboli
Slowing consumption of coagulation factors – Heparin
Assessment and monitoring
Focuses on Support vital functions
Initiate bleeding precautions
Meticulous skin care
Skin care: Assessed for signs of bleeding and thrombi: petechiae/petechial rashes, ecchymosis, epistaxis, hematuria, lumps or bumps that indicate hematoma. . .
Nursing management
Administer IVF, blood products, and medications ordered by PCP
Assess vital signs, hemodynamic parameters - keep within these, assess I & O, monitor laboratory values (not only associated with coag values but also with end organ perfusion)
Assess for bleeding and thrombi (Table 37.2): Assess neuro status, respiratory effort, cardiopulmonary function, and integumentary condition. - assessing for thrombus in periphery and bleeding
Focuses on Support vital functions
1 thing do once diagnosed with DIC - initate this
Avoid unnecessary venipunctures or arterial punctures
Cluster lab draws
Draw blood existing arterial or venous lines.
Avoid manual and automatic blood pressure cuffs - impossible but normally get manual when know systolic is lower
Use low-level suction is recommended - intubated/require suction; higher pressure - trauma in oropharynx and down - hemorrhage
Initiate bleeding precautions
Look at skin
Keep skin moist and using specialty mattresses and beds as appropriate to prevent breakdown.
Gentle care is used when bathing or turning the patient to prevent bruising or hematoma formation and not bumping body into side rails
Lotion up so not crack skin because that will hemorrhage and holding pressure
Meticulous skin care
No; everything is WDL; perfect assessment and want to see this
A 52 year old patient is admitted to the oncology unit with a diagnoses Acute Promyelocytic Leukemia (APL). PMH: Htn, hyperlipidemia, APL, appendectomy. Medications: Pt is receiving chemotherapy through a central line. Labs: Hemoglobin 10 g/dL, Platelets 100,000/mm3, Fibrinogen 160 mg/dl, International normalization ratio (INR) 1.6.
Neuro: A & O x 4.
CV: heart sounds were audible with regular rate and rhythm, normal S1 and S2, no murmurs. Pulses 2+ bilaterally. Cap refill < 3 sec.
Resp: Clear to auscultation (CTA)
Abdomen: Bowel sounds x 4 quads.
Pain: generalized 2/10
Integumentary: WDL
Vitals: BP 121/72, HR 81, RR 18, SpO2 98% on RA.
Is this assessment concerning?
Yes - whole assessment concerning
Clotting
disoriented and lethargic - thrombi in brain
Bilateral lower extremities: Petechiae
Capillary refill > 3 sec. Fingers and toes are pale/blueish
Bleeding
A very large pool of blood is on the bed and pt.’s gown.
epistaxis
Right thigh has a palpable hematoma the size of an orange.
Oozing around central line insertion site.
Consider if clotting and/or bleeding
The nurse enters the patient’s room to complete the noon assessment.
The patient is disoriented and lethargic. - must reorient
A very large pool of blood is on the bed and pt.’s gown.
Pt has epistaxis (nose bleed - no idea how long, cause or why)
Bilateral lower extremities: Petechiae are present.
Right thigh has a palpable hematoma the size of an orange.
Capillary refill > 3 sec. Fingers and toes are pale/blueish
Oozing around central line insertion site.
Should the nurse be concerned?
DIC
Not only looking at clotting factors; also end organ perfusion probs
SpO2 low - Resp effort high - may be thrombi in lungs; HR high - what RBCs present - may be something cardiac
Fever - underlying infection
Consider what end organs affected
Lethargic - something neuro - bleed or thrombi in brain
s&s of thrombus and bleeding
Hgb dropped
Platelet dropped by more than 50% and less than 50,000
PT elevated, fibrinogen = low
D-dimer = elevated
Cr elevated
Low grade temp
BP low side
HR high
RR high
SPO2 low
The nurse was concerned and called the physician. Orders to draw blood were received.
“Stat” laboratory studies:
Hemoglobin 8 g/dl, platelet count 32,000/mm3, prothrombin time (PT)15.8 seconds, INR 2.0, fibrinogen 90 mg/dl, and D-dimer 300 ng/mL, Creatinine 3.8mg/dL
Vital signs: T 100°F, BP 90/50 mm/Hg, pulse 120, RR 22 SpO2 90%.
Can you make a diagnosis?
Medical management
Treat underlying cause - chemotherapy and cancer
Maintain organ perfusion
Can anticipate this
Maintain euvolemia - IV fluids; support BP with + inotropes
Slow consumption of coagulation factors
If lab data supports it
What orders should the nurse anticipate?
Support vital functions
Initiate bleeding precautions
Assess for complications
Provide comfort & emotional support
Nursing management
Primary func
Give IV fluids - maintain adequate end organ perfusion
Blood products if promoted by labs
RBCs give if low RBCs
FFP for elevated PT/INR
Platelets for <50000
Cryo for low fibrinogen
Meds to ensure adequate hemodynamics - inotropes or vasoactive meds
I&O - indicates kidneys adequately perfused; output drops off - dealing with thrombi in kidney
Monitor labs
Monitor VS
Support vital functions
Handle the patient gently.
Protect the patient from trauma.
Avoid IM injections and venipunctures.
Apply firm pressure to any puncture sites for at least 10 min or until site no longer oozes blood.
Apply ice to areas of trauma.
Avoid the use of manual or automatic blood pressure cuff.
Observe IV sites every few hours for bleeding.
Shave the patient with an electric shaver only.
Use a soft-bristled toothbrush when providing mouth care.
Test urine and stool for occult blood as ordered.
Initiate bleeding precautions
Use a draw sheet when repositioning the patient in bed.
Instruct the patient to notify the nurse immediately if bleeding or bruising is noted.
Handle the patient gently.
Avoid rectal temperatures, enemas, and suppositories.
If suppositories are prescribed, lubricate liberally and administer with caution.
Initiate fall precautions.
Instruct the patient to notify the nurse immediately if any trauma occurs.
Protect the patient from trauma.
If necessary, use a small-gauge needle or IV cannula.
Avoid IM injections and venipunctures.
If necessary, remove cuff immediately after using it.
Do not leave cuff on the patient.
Avoid the use of manual or automatic blood pressure cuff.
In kidneys - urine output; elevated Cr
LFTs - assess liver
CV - perfusion, cap refill, HR
Respiratory effort
Neuro
Altered assessment - know hemorrhage or thrombi in one organs
Assess for complications
Conditions associated with DIC
Sepsis, Metabolic acidosis, hypoperfusion, Trauma, burns, Obstetric emergencies, cancer
Burns 30% or greater
Laboratory tests/results used to diagnose DIC
Laboratory results that indicate end organ perfusion
Assessment
s/s of bleeding
s/s of thrombi
s/s of end organ damage/perfusion
Nursing management
Key points
Symptoms usually occur 5 – 10 days after being exposed to heparin.
Symptoms more severe
MUST discontinue all heparin products. - anything with heparin - cannot have it
Immune mediated - Heparin-induced thrombocytopenia (HIT)
Clinical manifestations
Laboratory findings
Assessment and dx - Heparin-induced thrombocytopenia (HIT)
r/t to thrombus formation after heparin exposure
Only sx of thrombus formation
Most thrombus are venous: DVT
Arterial thrombus: thrombotic stroke, limb ischemia, PE, myocardial infarction.
Symptoms
Clinical manifestations
Correlate with the system affected
Make sure know how to assess
Doppled pulses on all extremities, toes blue, petechial hemorrhage in nail beds - limb ischemia
Abrupt resp distress - PE
Headache or expressive aphasia, decreased LOC - decline neuro status - thrombotic event
Cardiac
Vascular
Pulmonary
Renal
GI
Neurologic
Laboratory
Symptoms
Chest pain, diaphoresis, pallor, alterations in BP, dysrhythmias
Cardiac
Arterial: pain, pallor, pulselessness, paresthesia, paralysis
Venous: pain, tenderness, unilateral leg swelling, warmth, erythema, palpable cord, pain on passive dorsiflexion on foot, spontaneous maintenance of relaxed foot in abnormal plantar flexion (Homans sign)
Vascular
Dyspnea, pleuritic pain, rales, chest pain, chest wall tenderness, back pain, shoulder pain, upper abdominal pain, syncope, hemoptysis, SOB, wheezing
Pulmonary
Thirst, decreased urine output, dizziness, orthostatic hypotension
Renal
Abdominal pain, vomiting, bloody diarrhea, abnormal BS
GI
Confusion, headache, impaired speech patterns, hemiparesis or hemiplegia, vision disturbances, dysarthria, aphasia, ataxia, vertigo, nystagmus, sudden decrease in consciousness
Neurologic
Platelets <50,000/mm3 or sudden drop of 30-50% from baseline; positive results for HIPA, SRA, ELISA
Laboratory
Looking at platelet count only
A platelet count of less than 50,000/mm3 or a sudden drop of 50% from the patient’s baseline after initiation of heparin therapy (Immune mediated HIT)
Assays: heparin-induced platelet aggregation - not diagnostic in first part when trying to figure it out - to get heparin induced platelet assay - lab sent out hospital and takes days-weeks to get back
Immunosorbent assay: identifies the presence of the HIT antigen
Laboratory findings
Direct thrombin inhibitors: Argatroban
Pt requires antcoag and know hx of HIT - alternativative - Argatroban so blood not clot on equipment
Medical management - Heparin-induced thrombocytopenia (HIT)
Decrease the incidence of heparin exposure
Maintain surveillance for complications - esp pt not had dose of heparin ever - know giving first dose - monitor s&s of HIT - need actually feel pulses on all extremities so not cold extremity; color skin; listen to lungs; in room - note if respiratory distress, complaining chest pain, frequent headaches
Provide comfort and emotional support - gets HIT: this is primary purpose; other products such thrombin inhibitors if require anticoag or Argatroban for IR or diagnostic procedures
Educate the patient and family
Decrease anxiety
Nursing management - Heparin-induced thrombocytopenia (HIT)
Doc whole assessment and while documenting see if erythema new - need track erythema
CV - irregular rhythm - expected since in afib
Resp - right side - right pleural effusion
Pain - pleuritic - pleural effusion
Skin - assess if fallen or banged on knee on bed rail, dropped something - red and starting to hurt
The nurse is caring for a 52 year old patient who was admitted with a. fib RVR, and a pleural effusion 5 days ago. PMH: Hypothyroidism, hypertension, a. fib, GERD and peptic ulcer disease. Medications: Levothyroxine, Coreg, Pepcid, Heparin drip, IV Cefepime and Ciprofloxacin. Labs: Hemoglobin: 14g/dL; Hematocrit 40%; WBC 9,000/mm3; Plt 155,000/mL. Coags: PTT: 65 sec (normal for heparin therapy)
Neuro: No neuro deficits noted
CV: heart sounds were audible with irregular rhythm, normal S1 and S2, no murmurs. Pulses 3+ bilaterally; skin tone normal for ethnicity; extremity sensory, motor and sensation intact.
Vital signs: BP 122/77, HR 86, RR 16, SpO2 97% on RA, T 98.9°F
Resp: Diminished bilaterally, right side greater than left.
Abdomen: Bowel sounds x 4 quads.
Pain: Right sided pleuritic chest pain: dull, 3/10 in severity, aggravated by deep respiration. Right lateral knee pain 2/10.
Integumentary: Erythema on the lateral aspect of the right knee. Patient denies any trauma.
What should the nurses next actions be?
Yes
Right pedal pulse - swelling great enough not feel pulse - arterial thrombosis
Other classic DVT
Revisit pleuritic pain - could have PE - because not likely effusion more likely PE
More reddy purple
Warmer than left leg
Assessment has changed
Patient repositioned and Tylenol given for pain management.
Morning medications given: Levothyroxine, Coreg, Pepcid. Heparin drip rate unchanged.
45 minutes later. . . The nurse re-assessed the patient’s pain only to discover the entire right is swollen, and now tender to touch. The area of erythema is still present. The right leg measures 22cm and the left measures 18cm. Right pedal pulse 1+.
Is this concerning?
Labs:
Blood - platelets
Diagnostics:
Leg - highly probable likely have DVT - US to rule in/out DVT
Pleuritic pain - lungs if pt more dyspneic or having resp distress to rule out PE
Arterial pulse becomes not palpable or doppled - arteriogram
The nurse determines the change in assessment is concerning. The physician is notified.
What orders should the nurse anticipate?
s&s from clots developing and has thrombus somewhere in right calf causing DVT
Greater than 50% than last set labs of platelets
Drop in platelets heparin therapy - developing HIT
The labs are resulted: Hemoglobin: 14g/dL; Hematocrit 40%; WBC 9,000/mm3; Platelets 50,000/mL. Coags: unchanged
What is going on with this patient?
Priority: Stop heparin immediately
Any heparin containing product stopped immediately
Facilitate getting timely diagnostics done
What are the priority actions?
HIT
Diagnosis:
Need to decrease heparin
Stop any and all heparin admin immediately
Assess for comps - new or worsening of already documented comps
Educate pt and fam
Nursing management
Assessment findings associated with HIT
The patient must be exposed to Heparin. To develop HIT - types: drip, lovenax, low dose subQ heparin for DVT prophylaxis
Laboratory tests used to diagnose HIT
Platelet count - below 50,000 or drop 50% or more
Nursing management
Specifically stop heparin immediately if diagnosed with HIT
Summary
chest pain, diaphoresis, pallor, alterations in BP, dysrhythmias
Cardiac:
Arterial: pain, pallor, pulselessness, paresthesia, paralysis
Venous: pain, tenderness, unilateral leg swelling, warmth, erythema, palpable cord, pain on passive dorsiflexion on foot, spontaneous maintenance of relaxed foot in abnormal plantar flexion (Homans sign)
Vascular
Dyspnea, pleuritic pain, rales, chest pain, chest wall tenderness, back pain, shoulder pain, upper abdominal pain, syncope, hemoptysis, SOB, wheezing
Pulmonary
Thirst, decreased urine output, dizziness, orthostatic hypotension
Renal
Abdominal pain, vomiting, bloody diarrhea, abnormal BS
GI
Confusion, headache, impaired speech patterns, hemiparesis or hemiplegia, vision disturbances, dysarthria, aphasia, ataxia, vertigo, nystagmus, sudden decrease in consciousness
Neurologic
Platelets <50,000/mm3 or sudden drop of 30-50% from baseline; positive results for HIPA, SRA, ELISA
Laboratory
