Bleeding and clotting emergencies in the ICU (DIC, low platelets, HIT) and tumour lysis: what nurses watch
- Assessment
Nurses watch for bleeding from many sites, new clots, falling platelets and, after cancer treatment, rising potassium and falling urine.
What it is
Some ICU emergencies are found first by the nurse at the bedside. In disseminated intravascular coagulation (DIC) the clotting system is switched on throughout the body: small clots block organs and the clotting factors are used up, so the patient bleeds from many sites. In heparin-induced thrombocytopenia (HIT) an immune reaction to heparin lowers the platelets and, paradoxically, causes clots. In tumour lysis syndrome, cancer cells broken down by treatment release potassium, phosphate and uric acid, which can cause arrhythmias, seizures and kidney injury. The nurse's job is to look for the signs, follow the laboratory trends, keep urine output and fluids under watch, and call early.
Reference values
- DIC tests: blood count with smear, PT, PTT, fibrinogen and D-dimer.
- DIC risk factors: severe infection, cancer (above all some leukaemias), pancreatitis, liver disease, pregnancy complications, recent surgery, burns, head injury and transfusion reactions.
- HIT probability is estimated with the 4T score (degree of thrombocytopenia, timing, thrombosis, other causes); a low score makes HIT unlikely.
- Tumour lysis is diagnosed with two laboratory criteria (potassium, phosphate or uric acid above normal or rising by at least 25 %) plus one clinical criterion such as kidney injury, seizures or arrhythmia.
- Prevention of tumour lysis rests on intravenous hydration started before chemotherapy in high-risk patients, with a high urine output goal set by the team.
What you need
- Cardiac monitor and frequent vital signs.
- Hourly urine measurement and a fluid balance chart.
- Laboratory schedule: blood count, clotting tests and electrolytes as ordered.
- A complete list of every product that contains heparin in the patient's orders.
How to measure it (and why)
- Inspect every puncture site, wound, drain, the mouth, the urine and the stools each shift — bleeding from many sites at once suggests DIC.
- Look for signs of clots: a cold, pale or painful limb, chest pain, breathlessness, confusion — DIC and HIT both cause clots.
- Follow the platelet trend, not just the last value — a fall during heparin raises the question of HIT.
- If HIT is suspected, report it and review with the team every order and solution that contains heparin — all heparin must stop when ordered.
- In a patient starting cancer treatment, measure urine every hour and keep the fluid balance — falling urine is an early sign of kidney injury.
- Keep the cardiac monitor on and check potassium, phosphate, calcium and uric acid at the set times — high potassium causes arrhythmias.
- Watch for muscle spasms (tetany) and seizures — low calcium can cause both.
- Send the ordered tests (blood count, PT, PTT, fibrinogen, D-dimer) on time and report the results — they confirm DIC and guide treatment.
How to read it
- In DIC, bleeding and clotting happen at the same time; the treatment is mainly to treat the cause, with plasma or anticoagulation as the team decides.
- In HIT the main danger is clotting: a falling platelet count with a new clot is typical.
- Hyperkalaemia is the most dangerous change in tumour lysis; kidney injury can come from crystals of uric acid or calcium phosphate.
- Tumour lysis and DIC can occur together in patients with cancer.
Next step: when to call for help
- Call at once for bleeding that does not stop with pressure or for new bleeding from several sites.
- Call for a sudden fall in platelets or any new sign of a clot in a patient receiving heparin.
- Call for urine output below the goal, new palpitations or ECG changes, muscle spasms or seizures in a patient at risk of tumour lysis.
- Report critical laboratory values as soon as they are received.
Test yourself
Think of the answer, then tap the question to see it.
Why does a patient with DIC bleed and clot at the same time?
Because the clotting system is switched on throughout the body: small clots block vessels while clotting factors are used up, so bleeding follows.
When should a nurse think of heparin-induced thrombocytopenia?
When the platelet count falls or a new clot appears in a patient receiving heparin.
Which electrolyte change in tumour lysis is the most dangerous, and why?
High potassium, because it can cause arrhythmias and sudden death.
What is the main measure to prevent tumour lysis syndrome in high-risk patients?
Intravenous hydration started before chemotherapy, with close watch of urine output and electrolytes.
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Disseminated intravascular coagulation (DIC), Medical Encyclopedia (MedlinePlus, US National Library of Medicine, 2024); Heparin-induced thrombocytopenia: a review of new concepts in pathogenesis, diagnosis, and management (Journal of Clinical Medicine, 2021); Prevention and management of tumor lysis syndrome in adults with malignancy (Journal of the Advanced Practitioner in Oncology, 2013); Tumor lysis syndrome in solid tumors: a comprehensive literature review, new insights, and novel strategies to improve outcomes (Cureus, 2020).
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