Thread by @nihardesai7

You are a young #medicine resident !!

35/♀️/ wheeled in with 1 e/o seizure f/b loss of consciousness😮

Urgent CT👇🏻

Husband reveals she was on blood thinners after her ♥️ surgery, 5 yrs ago 😱

How do you manage this patient?

Read this thread to know more 👇🏻

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1/12

Yes, the CT shows a large hematoma

The patient was most likely on a vitamin K antagonist (VKA) post her prosthetic valve surgery!

The labs are back, she has also started to 🩸 through Foley's catheter😭

•CBC: 8/5600/201k
•INR: 8.8
•aPTT: 32s (control 29s)

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2/12

This is a classic example of warfarin toxicity & unfortunately quite commonly seen here in 🇮🇳

Why ?

The therapeutic window is 👇🏻

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3/12

Also, a lot of drugs/food interact with VKA 🔄

I always ask patients about recent antibiotics/over the counter/herbal products !

Antibiotics are the most common culprit and every tom, dick and harry gets amox-clav in 🇮🇳

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4/12

Our patient also took some antibiotic a couple of days back and now this 😭

How do we manage this now ?

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5/12

Call neurosurgery, STAT 📞☎️

Start supportive care, STAT

Anti-oedema measures, STAT

Protection of airway, breathing, circulation as always

STOP WARFARIN (obviously)

And something more 👇🏻

6/12

How do we reverse the anticoagulant effect that's already present ??

Many options:
1. 4 factor PCC
2. Recombinant factor 7a
3. FFP
4. Vitamin K

She should definitely get 10mg of vitamin K iv, STAT 👍🏻

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7/12

What's 4 factor PCC ??

It's a pathogen-reduced, lyophilized concentrate of 4 clotting factors:

Factor II
Factor VII
Factor IX
Factor X

These are the factors the VKA have depleted, so we replace them 👍🏻

But why not FFP?

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8/12

Simple, FFP = more volume
FFP = less concentrated w/ factors
FFP = chance of blood borne infections

So FFP only if If PCC isn't available 🙏🏻

How much FFP ?

Give 2 units➡️measure INR➡️still >1.5➡️give 2 more units and so on !!

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9/12

We have PCC in the hospital, what's the dose used ??

2000 units iv over 10minutes
⬇️
Check INR after 20-30min
⬇️
If >1.5
⬇️
Repeat the dose again (50units/kg)

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10/12

Husband asks, how's the prognosis??

This is THE MOST FEARED COMPLICATION of warfarin.

Outcomes, unfortunately not so good.

The larger the bleed, poorer the outcome.

Early reversal of AC and rapid neurosurgical evaluation are a must

jamanetwork.com/journals/jaman…

11/12

Summary:

Warfarin- narrow therapeutic index
Lots of interactions
Intracranial hemorrhage is 😭
Rapid reversal necessary pre surgery
PCC>FFP
Vitamin K✅

Outcomes remain poor, best to prevent this complication. Adequate councelling at the time of initiation is important 🙏🏻

End.

As always 👇🏻

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