NUR 401 Clotting

​Clotting

By Miranda Smith

Pancreatitis

You ever make a bad decision and immediately regret it? Such as, taking a bite of gas station sushi and 30 min later, you're bargaining with a higher power in the bathroom floor? This is how the pancreas feels when it sees alcohol coming--- It's like, 'Oh great, here we go again.'

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Your pancreas is that friend who just can't handle their liquor. If they drink too much they lose total control and start wrecking the place. But instead of breaking furniture, the pancreas starts to digest itself. YES--it's like a blender that turns on without a lid, spraying enzymes everywhere and before you know it, the whole house (or abdominal organs) is a disaster zone and your body is in full blown inflammation mode.

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Pancreatitis

• Acute pancreatitis is a sudden inflammatory process of the pancreas, which leads to enzyme activation and pancreatic tissue damage due to autodigestion of the pancreas itself.

• Can be mild-severe, with severe cases causes systemic effects such as:

  • ARDS

  • Sepsis

  • MODS

Multiple Choice

What is the most common cause of pancreatitis?

• Pancreatic Cancer

• Gallstones

• Alcohol consumption

• Diabetes Mellitus

Pancreatitis

• Most commonly caused by GALLSTONES and alcohol consumption

• Mild pancreatitis- Localized inflammation, NO ORGAN FAILURE, good prognosis

• Moderately Severe- Transient organ failure (< 48 hours), potential complications

• Severe Pancreatitis- PERSISTENT ORGAN FAILURE (> 48 hrs), associated with high mortality from complications- Sepsis & ARDS

Drag and Drop

Which 2 laboratory values are the most indicative of acute pancreatitis?​

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Drag these tiles and drop them in the correct blank above

Lipase

Amylase

Glucose

Bilirubin

Sodium

ALT

AST

S/S:
Severe abdominal pain
Nausea & Vomiting
Rigid Abd & Guarding
Decreased or Absent Bowel Sounds
Hypotension
Tachycardia
Jaundice

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Pancreatitis

Diagnosis

​Requires 2 of the 3 criteria:

1. Epigastric pain radiating to the back

2. Amylase & Lipase elevation 3 X the upper limit

3. Characteristic findings on the CT

Multiple Choice

A client presents to the ED with severe epigastric pain radiating to the back with nausea, and vomiting. Which additional assessment finding is the MOST concerning?

• Cullen's Sign

• Rebound Tenderness

• RLQ Pain

• Rovsing's Sign

Signs of intra-abdominal bleeding= SEVERE PANCREATITIS

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Multiple Choice

Which is not a systemic complication of acute pancreatitis?

• ARDS

• AKI

• Increased Cardiac Output

• DIC

Common Complications

• Pulmonary- ARDS, hypoxemia, pneumonia, pleural effusion

• Cardiovascular- Hypotension, hemorrhage, pericardial effusion

• Renal- Acute tubular necrosis (ATN), AKI4

• Hematologic- DIC

• Metabolic- Hyperglycemia, metabolic acidosis, hypocalcemia

• GI- Bleeding, pseudocyst, peritonitis

Treatments

• NPO with NG tube (although, they are going away from this)

• IV Fluids and Albumin

• PPIs to decrease pancreatic enzymes

• Antibiotics

• ERCP (Endoscopic Retrograde Cholangiopancreatography)

Multiple Choice

A client with acute pancreatitis develops respiratory distress and requires high levels of oxygen supplementation. What is the most likely complication

• Pleural effusion

• ARDS

• Pulmonary embolism

• Aspiration pneumonia

Multiple Choice

A client with severe pancreatitis has worsening hypotension, tachycardia, and decreased urine output despite fluid resuscitation. What is the next best intervention?

• Start vasopressors

• Increase IVF

• Start hemodialysis

• Prepare for an emergency laparotomy

Liver Failure

Liver FAilure

Now imagine your liver is like a bouncer at an exclusive club, filtering out trouble makers (toxins, ammonia, drugs). But one day, the bouncer gets really drunk (liver failure), stops checking IDs, and lets everyone in. Now the place is full of ammonia, the bartenders (clotting factors) are overwhelmed, and security (immune system) is asleep on the job. The next thing you know, people are acting crazy (hepatic encephalopathy), bar fights are breaking out (bleeding issues), and the place is a disaster.

liver failure

Acute liver failure is the rapid loss of liver function, leading to toxin accumulation, coagulopathy, hepatic encephalopathy, and multi-organ failure There is a high mortality rate without any intervention.

Multiple Choice

What is the primary mechanism leading to hepatic encephalopathy in liver failure?

• Increased glucose metabolism

• Decreased production of clotting factors

• Accumulation of ammonia and neurotoxins

• Excessive bile production

Liver Failure

• Hepatocyte Damage--> Widespread liver cell destruction

• Loss of liver function --> Impaired detoxification of the blood

• Ammonia Accumulation--> Hepatic encephalopathy

• Coagulopathy--> Increased risk of bleeding

• Cerebral Edema and MODS--> High mortality Risk

Multiple Choice

What is the leading cause of acute liver failure in the US?

• Acetaminophen OD

• Chemotherapy drugs

• Viral Hepatitis

• Alcohol use

• Drug Induced- Acetaminophen, NSAIDS, anti-TB meds, chemotherapy

• Viral Hepatitis- HBV, HCV (most common), CMV, EBV, HSV

• Metabolic Disorders- Wilson's Disease (copper accumulation)

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Causes of Liver Failure

Multiple Choice

Which is NOT commonly used to diagnose liver failure?

• Liver function tests

• PT/INR

• Ammonia Levels

• D-Dimer

Diagnosis

• Blood Tests- LFTs, PT/INR, CBC, Hepatitis serologies

• Imaging- CT (massess/abscess), US (vascular obstruction), MRI (Wilson's Disease)

Multiple Choice

What is the most life-threatening complication of liver failure?

• Hepatic encephalopathy

• Cerebral Edema

• Hypoglycemia

• Ascites

complications

• Hepatic Encephalopathy-Confusion-> Stupor-> Coma

• Cerebral Edema-Increased ICP-> Brain herniation

• Coagulopathy- Bleeding risk from decreased clotting factors

• Hypoglycemia-Impairs glucose regulation

Multiple Choice

A client with hepatic encephalopathy develops a flapping tremor when holding their hands outstretched. What is this sign called?

• Myoclonus

• Babinski Reflex

• Grey Turner Sign

• Asterixis

Hepatic encephalopathy

• Grade I: Personality changes, decreased attention span

• Grade II: Disorientation, incontinent, asterixis

• Grade III: ICU admission, requires intubation

• Grade IV: Come, unresponsive

Ammonia is able to cross the blood-brain barrier and cause AMS.

Rifaximin reduces gut bacteria that produces ammonia, adjunct to lactulose and used in combination with lactulose to further reduce ammonia levels in pts with hepatic encephalopathy. it is helpful when ammonia remains increased despite lactulose

Multiple Choice

What is the most effective treatment for reducing ICP in cerebral edema?

• Low-protein diet

• Acetaminophen

• Hypertonic IVFs

• Hypotonic IVF

cerebral edema

• Intracranial pressure monitoring

• Hypothermia to reduce metabolic demand

• Hypertonic Saline (3%) or mannitol

• Inc HOB 30 degrees to reduce ICP

Multiple Choice

A client who has liver failure presents with massive hematemesis (vomiting bright red blood), hypotension, and tachycardia. What is the most likely cause?

• Mallory-Weiss Tear

• Peptic Ulcer Disease

• Esophageal Variceal Rupture

• Acute gastritis

​Liver failure can lead to gi bleed

• Caused by Portal Hypertension

• Treatment: Octreotide, endoscopic band ligation, Sengstaken-Blakemore Tube

Multiple Choice

Which lab finding is most concerning for spontaneous bacterial peritonitis (SBP) in a client who has ascites?

• Albumin < 3.5

• PMN (polymorphonuclear neutrophils) > 250 in ascitic fluid

• Elevated ALT/AST

• Hypoglycemia

spontaneous bacterial peritontis

• Treatment: IV Cefotaxime (Claforan)

• Monitor for fever, worsening mental status

Multiple Choice

A client who has acute liver failure has an INR of 6.8, ammonia 150, and worsening confusion. The client is now drowsy and minimally responsive to verbal stimuli. What is the priority nursing action?

• Administer fresh frozen plasma

• Start lactulose and monitor for hepatic encephalopathy

• Intubate and prepare for a liver transplant evaluation

• Administer IV Vitamin K

Multiple Choice

A client who has cirrhosis and ascites suddenly develops fever, worsening abdominal pain, and altered mental status. What is the priority nursing action?

• Administer diuretics to remove excess fluid

• Prepare for a diagnostic paracentesis

• Increase albumin infusion

• Monitor ammonia levels before taking action

Multiple Choice

A client who has massive hematemesis from esophageal varices is hypotensive and tachycardic. What is the MOST URGENT intervention?

• Start Octreotide IV

• Endoscopic band ligation

• Prepare for Sengstaken-Blakemore tube

• Emergently transfuse PRBCs

Multiple Choice

A client who as grade III hepatic encephalopathy is intubated and receiving lactulose via NG tube, but ammonia remains elevated. What would be the next best step?

• Increase lactulose dose

• Start Rifaximin therapy

• Check liver transplant eligibility

• Start IV glucose infusion

Multiple Choice

A client with acute liver failure has persistent lactic acidosis, worsening mental status, and rising bilirubin despite aggressive management. What is the definitive treatment?

• Continuous renal replacement therapy

• High dose of steroids

• Plasma exchange

• Liver transplant

GI Bleed

GI Bleed

Have you ever made coffee and then forgot about it until the next day? You go to dump it out and instead of fresh liquid, it's this weird, thick, black sludge at the bottom of the pot. This is what happens when blood sits in your stomach--it turns into coffee ground emesis. So if you every hear a patient say "it looks like coffee" you know the blood has been there long enough to ...age..

Upper GI bleeds can cause "coffee grounds" if the blood sits in the stomach and it gets partially digested.

A GI bleed refers to any bleeding that occurs in the gastrointestinal tract, which can be upper (above the ligament of Treitz) or lower GI (below the ligament). It can be overt (visible) or occult (hidden, only detected through testing.

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GI Bleed

Multiple Choice

What is the mortality rate associated with GI bleeds?

• 1-2%

• 5-10%

• 10-15%

• 15-20%

Multiple Choice

Which is not a common cause of UPPER GI bleeding?

• Peptic ulcer disease

• Esophageal varies

• Diverticulosis

• Mallory-Weiss Tear

Diverticulosis
AV malformations
Ischemic colitis
Hemorrhoids

Lower GI

Peptic ulcer disease
Esophageal varices
Stress ulcers
Mallory-Weiss tears
Gastritis

Upper GI

GI Bleeds

Multiple Choice

What is the most common cause of Upper GI bleeds?

• Peptic ulcers

• Gastritis

• Mallory-Weiss tear

• Esophageal Varies

• Peptic Ulcers: Occur in the stomach or duodenum

• Risk factors: H. Pylori, NSAIDS, smoking

• Symptoms: Epigastric pain, melena, hematemesis

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Client will complain of a gnawing type of pain in the stomach.

Peptic Ulcer Disease

Multiple Choice

Which medication is the first-line treatment for esophageal bleeding?

• Pantoprazole

• Octreotide

• NSAIDS

• Maalox

• Esophageal varices are dilated veins in the esophagus caused by portal hypertension

• Treatment

  • Octreotide (Reduces portal HTN)

  • Endoscopic band ligation

  • Sengstakin-Blakemore tube (uncontrolled bleeding)

    When bleeding is uncontrolled--Intubate to protect airway.​

Esophageal Varices

Sengstaken-Blakemore Tube

​Signs and Symptoms

• Hematochezia: Bright red/maroon stool (lower GI)

• Melena: Black, tarry stool (Upper GI)

• Hematemesis: Vomiting blood (Upper GI)

• Occult bleeding: Hidden, cannot see, detected with guaiac testing

• Hypotension

• Tachycardia

Multiple Choice

Which ICU client is the most at risk for a stress related mucosal disease (SMRD)?

• One's who take anticoagulants such as Eliquis

• Critically ill clients who are mechanically ventilated

• Clients who have GERD

• Client's who have chronic constipation

​Stress related Mucosal Disease

• SMRD= Acute ulcers in critically ill clients

• 75 % of ICU clients develop evidence of mucosal injury within 24 hours

• Prevention: PPI prophylaxis, early enteral feeding

Multiple Choice

What is the primary cause of a Mallory-Weiss tear?

• Excessive alcohol consumption
• Eating spicy foods
• Taking certain medications
• Severe vomiting or retching

• Linear lacerations at the gastroesophageal junction

• Causes: Retching, vomiting, alcohol abuse, bulimia

• Symptoms: Hematemesis, epigastric pain, melena

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Mallory-Weiss Tear

Multiple Choice

What is the most common cause of lower GI bleeding?

• Hemorrhoids
• Gastritis
• Peptic ulcer
• Diverticulosis

• Diverticulosis: Most common cause, especially age > 60

• Other causes: AV malformations, Ischemic colitis, inflammatory bowel disease, colorectal cancer, hemorrhoids

• Symptoms: Bright red/maroon stool (hematochezia) or occult blood loss

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Lower GI Bleed

• Outpouchings of the colonic mucosa, most common in the sigmoid colon

• Risk: Age > 60, chronic constipation, low fiber diet

• Symptoms: Painless, large volume hematochezia

• Diagnosis: Colonoscopy (Gold standard) or CT angio for unstable

• Treatment:

  • Self limited, supportive care

  • IVF, Blood transfusion

  • Endoscopic (clip, cauterization, injection)

  • Angio Embolization if persistent bleeding

  • Surgery (colectomy) in severe cases.

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Diverticulosis

Multiple Choice

What is the primary treatment goal for ischemic bowel disease?

• Increase bowel motility to enhance digestion.
• Restore blood flow to the affected bowel segment.
• Administer antibiotics to prevent infection.
• Provide pain relief through narcotics.

• Ischemic colitis: caused by reduced blood flow to the intestines

• Risks: Elderly, atherosclerosis, clotting disorders, anticoagulant use

• Treatment: IVF, hemodynamic support, antibiotics if infection suspected

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Ischemic Bowel

Multiple Choice

Which inflammatory bowel disease is more likely to cause significant lower GI bleeding?

• Diverticulitis
• Ulcerative colitis
• Crohn's disease
• Celiac Disease

Inflammatory Bowel Disease

• Ulcerative Colitis: Affects the colon, causes blood diarrhea

• Crohn's Disease: Can affect any area of the GI tract, bleeding is less common

• Diagnosis: Colonoscopy with biopsy

• Treatment: Corticosteroids, immunosuppressants, biologic therapy

Multiple Choice

What is the most common symptom of colorectal cancer-related bleeding?

• Hematemesis

• Occult blood in stool

• Coffee-ground emesis

• Bright red blood per rectum

​Colorectal Cancer

• Can cause slow, chronic bleeding only detected by hemmocult

• Symptoms: Iron deficiency anemia, fatigue, weakness, guaiac-positive stool

• Diagnosis: Colonoscopy with biopsy

Multiple Choice

What is the first priority in managing a hemodynamically unstable client who has a GI bleed?

• Determine source of bleeding

• Administer PPIs

• Maintain airway and restore intravascular volume

• Start Octreotide infusion

​Management of GI bleed

• First priority: ABCs

• Resuscitation: IVFs (isotonic), blood transfusion

• Interventions: Endoscopy, medication therapy, surgery

Treatment

• Resuscitation and Stabilization (First Priority-The SHARK)

  • Airway protection: Intubate if altered mental status or massive hematemesis

  • IVF: Crystalloids (NS/LR) first, then blood transfusion

  • Vasopressors (if needed): For persistent hypotension despite fluid resuscitation
    

• Colonscopy (gold standard)

• Angiographic embolization: if endoscopic treatment fails

• Surgery (colectomy): Considered in massive or recurrent bleeding

Lower GI Bleeding

• PPIs: Pantoprazole IV drip (reduces acid and clot lysis)

• Octreotide IV: For variceal bleeding, reduces portal hypertension

• Endoscopic banding: Band ligation, thermal coagulation, clips

• Sengstaken-Blakemore: For uncontrolled variceal hemorrhage

Upper GI Bleed

Treatment

Additional Therapies

• Esophageal varices: antibiotics (ceftriaxone), beta blockers (propranolol-prevention)

• Peptic ulcer disease: H. Pylori eradication (triple/quad therapy: PPI, clarithromycin, amoxicillin/metronidazole; may have Pepto Bismol

• Diverticular Bleed: Supportive care, angiography if severe

• Ischemic Colitis: Bowel rest, IV fluids, possible surgery if infarction occurs

DIC

​DIC

So imagine you are at a party and there's one guest who is just way too extra. At first, they are throwing glitter everywhere (clotting like crazy), but suddenly, they start sobbing uncontrollably, smudging their make up and making a huge mess (bleeding because all the clotting factors are used up). That is DIC. Your body tries to be fancy and overdoes it, then suddenly crashes because it ran out of resources.

Multiple Choice

Disseminated Intravascular Coagulation (DIC) is best described as.....

• A primary coagulation disorder

• A condition where extreme bleeding occurs only

• A secondary condition causing excessive clotting and bleeding

• A rare autoimmune disorder

DIC

• Secondary condition that is triggered by sepsis, trauma, cancer, and obstetric emergencies

• Begins with excessive clotting--> depletes clotting factors--> Leads to uncontrolled bleeding

Multiple Choice

What is the initial even in DIC pathophysiology?

• Inhibition of platelet aggregation.
• Decreased fibrinogen levels.
• Increased blood viscosity.
• Uncontrolled activation of the coagulation cascade.

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