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Disseminated Intravascular Coagulation
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Hemostasis
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DIC
Disseminated Intravascular Coagulation
| Question | Answer |
|---|---|
| Disseminated Intravascular Coagulation | “ A pathological form of coagulation that is diffuse rather than localized, as would be the case with normal coagulation” |
| Hemostasis | Hemostasis is the stopping of bleeding Hemostasis is achieved when there is a balance between coagulation and bleeding There should be a balance between the two |
| Platelets | o First on the scene o When activated they clump together and begin the cascadeo They are a stop gap, they themselves cannot form a clot and maintain a clot on their owno They are the beginning of clot formationo Can be measured with a CBC or alo |
| Factors II, V, VII, VIII, X, XIII: | o part of the clotting cascade (all activated along)o Can be measured in an assay |
| Prothrombin | o The precursor to thrombin. o The time is takes on the conversion can be measured… the prothrombin timeo Coumadin prolongs PT (Heparin PTT- antithrombin III) |
| Thrombin | o Converts fibrinogen to fibrin. o Thrombin time is the time is takes for this conversion |
| Fibrinogen | o a protein that is converted to fibrino can be measured in a serum level |
| Fibrin | o A stringy protein that weaves through the platelets and helps form the clot |
| Fibrin degradation products/fibrin split products (FDP/FSP) | o released into the bloodstream after a fibrin clot is lysed (dissolved)o Elevated after a clot is lysedo Can be measured |
| D-dimers | formed when a plasmin digests clotted fibrino Can also be measured in the blood.o Sign of clot formation and subsequent lysis of a clot |
| Anti-thrombin III | o a naturally occurring coagulation inhibitor on our body’so Heparin works on this |
| Thromboplastin | o A coagulation factor in the blood and tissues that accelerates blood clotting.o Can be measured in seconds, (PTT or aPTT-same thing) |
| Plasminogen | o precursor of plasmin |
| Plasmin | o fibrinolytic enzymeo helps with the lysis of clot |
| Fibrinolysis | o dissolution of a fibrin doto breakdown of a clot |
| Normal coagulation | Begins with either intrinsic or extrinsic factors Intrinsic factors:o problems/substances in the blood itself that cause a clot to form Extrinsic factors: o trauma to the tissues or damage to blood vesselso outside (stab wound, surgery etc. |
| Intrinsic factors | problems/substances in the blood itself that cause a clot to form |
| Extrinsic factors | o trauma to the tissues or damage to blood vesselso outside (stab wound, surgery etc.) |
| Steps in Clotting Cascade | Injury Platelets (on the scene) Factors (activated-measured in an assay) Prothrombin Activator Prothrombin Thrombin ( converts fibrinogen to fibrin-what makes up a clot ultimately) Fibrin strands Fibrin clot Need to have all of t |
| After hemostasis (clot formation) is achieved | The body is working on fibrinolysis An automatic reaction The enzymes necessary for lysing a clot are located in the clot itself When the clot is dissolved fibrin degradation products (FDP’s or FSP’s) and fragment D (D-timer) are released into |
| Steps of Fibrinolysis | Clot formation Plasminogen Plasminogen activator Plasmin (goes to site) The breakdown of clot…release of FDP’s into blood (can be measured) lets you lysis of clots is occulting in the body TPA (tissue plasminogen activator) is given in ca |
| Pathophysiology of DIC | Diffuse activation of the complement system/clotting cascade, (due to an underlying disease process- Gram- sepsis, liver disease), causes formation of thousands of small clots through the whole body. These clots occur in capillaries of the skin, lung |
| Causes of DIC | Sepsis (most commonly gram-)/Endotoxins: which are released into the bloodstream that activate the compliment system (clotting cascade) Obstetrical conditions Malignancies: tumors can have necrotic breakdown, tumor necrosis factor is released in |
| In Relation to Septic Shock | The bacteria (usually Gram -) in the blood releases endotoxins which cause a systemic inflammatory reaction (SIRS-body wide inflammation) which activates the clotting cascade This begins in the hyperdynamic (warm) phase of septic shocko s/s of warm |
| Clinical Manifestations due to Thrombosis (Phase I) | Neuro: decreased alertness, possible CVA symptoms, change in level of consciousness Cardiovascular: decreased peripheral pulses (if emboli/thrombus forms in an artery supplying an extremity) Resp: hypoxia, inspiratory pain (caused by PE) Ren |
| Clinical Manifestations due to Hemorrhage (Phase II) | Skin: petechiae, oozing from mucous membranes, venipuncture, IV and surgical sites Resp: tachypnea, hemoptysis, hemothorax, SOB Cardiovascular: tachycardia, hypotension, decreased pulses GI: heme-positive stools (guaiac +), NG tube (hemoccu |
| Lab Values in DIC | o PT (10-13 sec): prolongedo PTT (25-39): prolongedo Platelets (150-450): decreased (because of diffuse clumping all over the body they are stuck in clumps and not circulating- not available in the body)o Thrombin time (17-25): prolongedo Fibr |
| PT (10-13 sec) | prolonged |
| PTT (25-39) | prolonged |
| Platelets (150-450) | decreased (because of diffuse clumping all over the body they are stuck in clumps and not circulating- not available in the body) |
| Thrombin time (17-25) | prolonged |
| Fibrinogen (200-400) | decreased (circulating in serum) |
| FDPs (less than 10) | increased in serum- works on lysing |
| D-dimers (less than 200) | increased (when clots are being lysed-see increase with pathological clots) |
| Treatment of DIC | The best tx os to prevent DIC (prevent bacteria from getting into the blood) or to detect it in it’s early stages (when thrombus are beginning to form, before all the clotting factors are consumed Tx/correct underlying cause (broad spectrum antibioti |
| Medications | Anticoagulants: can prevent the formation of further clot development and allow time for the clotting factors to replenish themselves by the liver before they have all been consumed Example: heparin (IV), low molecular weight (Lovenox) Used in t |
| Cryoprecipitate | o derived from plasma and concentrated fibrinogeno used when fibrinogen levels are low or with active bleedingo best if matched with blood typeo small volume given IV push |
| Fresh Frozen Plasma | o replenishes intravascular blood volume and clotting factorso has to be used immediately after thawingo given as rapidly as possible (usually within ½ hr)o must be matched with blood type |
| Platelets | o Given with thrombocytopenia and active bleedingo Can be multiple or single donor I one infusiono Given quickly oven 15-30 mino Fever is a common reaction to the foreign protein (not anaphylactic)o Blood type match is not necessary |
| Packed Red Blood Cells | o Given if H&H are significantly decreased due to hemorrhageo Usually an 250ml bago Must be infused within 4hrs or less because of bacteria contamination (has to be thrown out)o Watch for fluid overloado Must be matched to the pts blood type |
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littlemina
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