You are a young #medicine resident !!
35/โ๏ธ/ wheeled in with 1 e/o seizure f/b loss of consciousness๐ฎ
Urgent CT๐๐ป
Husband reveals she was on blood thinners after her โฅ๏ธ surgery, 5 yrs ago ๐ฑ
How do you manage this patient?
Read this thread to know more ๐๐ป
#MedTwitter
1/12
35/โ๏ธ/ wheeled in with 1 e/o seizure f/b loss of consciousness๐ฎ
Urgent CT๐๐ป
Husband reveals she was on blood thinners after her โฅ๏ธ surgery, 5 yrs ago ๐ฑ
How do you manage this patient?
Read this thread to know more ๐๐ป
#MedTwitter
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 ๐ฉธ through Foley's catheter๐ญ
โขCBC: 8/5600/201k
โขINR: 8.8
โขaPTT: 32s (control 29s)
#MedTwitter
2/12
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 ๐ฉธ through Foley's catheter๐ญ
โขCBC: 8/5600/201k
โขINR: 8.8
โขaPTT: 32s (control 29s)
#MedTwitter
2/12
This is a classic example of warfarin toxicity & unfortunately quite commonly seen here in ๐ฎ๐ณ
Why ?
The therapeutic window is ๐๐ป
#MedTwitter
3/12
Why ?
The therapeutic window is ๐๐ป
#MedTwitter
3/12
Also, a lot of drugs/food interact with VKA ๐
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 ๐ฎ๐ณ
#medtwitter
4/12
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 ๐ฎ๐ณ
#medtwitter
4/12
Our patient also took some antibiotic a couple of days back and now this ๐ญ
How do we manage this now ?
#medtwitter
5/12
How do we manage this now ?
#medtwitter
5/12
Call neurosurgery, STAT ๐โ๏ธ
Start supportive care, STAT
Anti-oedema measures, STAT
Protection of airway, breathing, circulation as always
STOP WARFARIN (obviously)
And something more ๐๐ป
6/12
Start supportive care, STAT
Anti-oedema measures, STAT
Protection of airway, breathing, circulation as always
STOP WARFARIN (obviously)
And something more ๐๐ป
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 ๐๐ป
#medtwitter
7/12
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 ๐๐ป
#medtwitter
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 ๐๐ป
But why not FFP?
#medtwitter
8/12
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 ๐๐ป
But why not FFP?
#medtwitter
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 ๐๐ป
How much FFP ?
Give 2 unitsโก๏ธmeasure INRโก๏ธstill >1.5โก๏ธgive 2 more units and so on !!
#medtwitter
9/12
FFP = less concentrated w/ factors
FFP = chance of blood borne infections
So FFP only if If PCC isn't available ๐๐ป
How much FFP ?
Give 2 unitsโก๏ธmeasure INRโก๏ธstill >1.5โก๏ธgive 2 more units and so on !!
#medtwitter
9/12
We have PCC in the hospital, what's the dose used ??
2000 units iv over 10minutes
โฌ๏ธ
Check INR after 20-30min
โฌ๏ธ
If >1.5
โฌ๏ธ
Repeat the dose again (50units/kg)
#medtwitter
10/12
2000 units iv over 10minutes
โฌ๏ธ
Check INR after 20-30min
โฌ๏ธ
If >1.5
โฌ๏ธ
Repeat the dose again (50units/kg)
#medtwitter
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/jamanโฆ
11/12
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/jamanโฆ
11/12
Summary:
Warfarin- narrow therapeutic index
Lots of interactions
Intracranial hemorrhage is ๐ญ
Rapid reversal necessary pre surgery
PCC>FFP
Vitamin Kโ
Outcomes remain poor, best to prevent this complication. Adequate councelling at the time of initiation is important ๐๐ป
End.
Warfarin- narrow therapeutic index
Lots of interactions
Intracranial hemorrhage is ๐ญ
Rapid reversal necessary pre surgery
PCC>FFP
Vitamin Kโ
Outcomes remain poor, best to prevent this complication. Adequate councelling at the time of initiation is important ๐๐ป
End.
โข โข โข
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