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Discussion

Help with a case?

I have had a case on the medical floor for the last couple of days and am wondering if any of you could give me some insight into the problem the patient was having.

Clinical Course

Male approx. 65 y/o

Day 1&2: Admitted with pneumonia and subsequently tx in normal fashion- ATB, 02, MNebs. Pt. started on 5000 Units of Heparin SQ/qd. I am unsure of why he needed this. I am guessing he was not moving around enough for the MD to be comfortable enough, so DVT proph. initiated.

Day3: Dx: with a cardiac tamponade and trans. for CCU where a pericardial window is preformed and 1.7L fluid removed. Cytology of fluid reveals CA (adenocarcinoma). MRI(I think) reveals mass in R lung.

Day 5: Pt. develops GI bleed with hypotension. Transferred to ICU 2U PRBCS transfused. Heparin Stopped.

Day 7: Pt. transferred to medical unit. Stable H/H holding around 28/9.5.

Day 8: Pt. becomes disoriented to place/time. Intermittently drowsy to lethargic for extended periods with intermittent R facial droop (literally comes and goes), grips equal/strong, no other deficits noted. No bloody stools noted, but pt experienced epistaxis of 30-45 min for me to control. H/H drops over last 24 hrs. to 25.4/8.7. Platelets go in 8 hrs from 57 to 46. They platelet numbers has been in the 80s to 120s over the last 5 days or so. I think they started the most precipitous drop on day 6-7. Wish I could remember more.

Could this be -Heparing induced thrombocytopenia? If the CA had spread to the bones I don't think it would cause such a precipitous drop in platelets. Did not see any reports about his spleen condition. Pt. also had cardiac stents placed in July. Could angiomax, or aggrastat cause a delayed rxn. like this? BTW-I called the hospitalist at 0100 to report the hemogram numbers, etc. and she didn't want to know his hx or anything. He had been a hospitalist pt all along. She also didn't give me any new orders. She just said follow existing orders, which was to transfuse 2U PRBCs if H/H drops below 8.5.

Is my logic ok on the possibilites with this pt.? I am fairly new to nursing and just want to make sure I am thinking correctly. Any ideas?

Featured Replies

First, nice job!

I think it could very well could be HIT as this typically doesn't show up for several days after initiating heparin treatment.

Here's something interesting to read about HIT:

http://www.chestjournal.org/cgi/content/full/122/1/37

Hope he was scanned for a stroke? Could have very well been hemorrhagic. His facial droop would have triggered a stroke code for us.

i don't know much about hit but it seems to me if the h/h is steady dropping with the platelets then perhaps theres internal bleeding somewhere. hopefully not cerebral since you were concerned about facial drooping. any changes in loc?

low platelet count could be perhaps related to cancer as well.

had an aids pt last week with platelets of 4 and 5 every day that weren't treated. i guess he had worse problems.

anyways, thats a toughie, sorry not much help, good luck to you!

Don't want to seem heartless but this guy needs a code status.

Sounds like a family meeting with the Docs is in order for this pt.

What does oncology say? Can they treat his CA? Has the pt. stated his wishes to anyone? Family member? Heathcare provider.

Sounds like his prognosis is grim. If it was me and oncology suggested poor survival rate, make me a DNR amd as comfy as possible. And let me go.

Walt :stone

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