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𝗡𝗶𝗵𝗮𝗿 𝗗𝗲𝘀𝗮𝗶

@nihardesai7

Apr 18 • 13 tweets • 7 min read Twitter logo

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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 👇🏻

#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 🩸 through Foley's catheter😭

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

#MedTwitter

2/12

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

Why ?

The therapeutic window is 👇🏻

#MedTwitter

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 🇮🇳

#medtwitter

4/12

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

How do we manage this now ?

#medtwitter

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 👍🏻

#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 👍🏻

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 🙏🏻

How much FFP ?

Give 2 units➡️measure INR➡️still >1.5➡️give 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
⬇️
Check INR after 20-30min
⬇️
If >1.5
⬇️
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/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 👇🏻

#medtwitter

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More from @nihardesai7

𝗡𝗶𝗵𝗮𝗿 𝗗𝗲𝘀𝗮𝗶

@nihardesai7

Apr 18

What does the 𝐖𝐀𝐑𝐅 in warfarin stand for??

Any ideas?

This is an interesting thread, let's dive into the history of one of the most widely used anticoagulants 👇🏻

#MedTwitter

Let's roll back time, we are in the 1930s in 🇺🇲, the great depression is at its peak and American farmers are losing their cattle 😭

How ??

Somehow the 🐄🐮 are developing fatal internal hemorrhages 😭😭

No one knew why !!

#MedTwitter

Obviously, their fodder was considered to be affected by some bug, but it wasn't to be found 🤷‍♂️

There wasn't any change in their diet, they were being fed sweet clover hay for centuries !!

#MedTwitter

Read 7 tweets

𝗡𝗶𝗵𝗮𝗿 𝗗𝗲𝘀𝗮𝗶

@nihardesai7

Apr 14

You are a young #medicine resident in a busy emergency when a 26/♂️ walks in with 👇🏻

C/o cough and respiratory distress + facial swelling x 7days. He is unable to sleep as the symptoms ⤴️ on lying down 😮

What do you do next?

You read this thread👇🏻

#medtwitter

1/18

You immediately know what's going on, you ask for an urgent chest imaging. Only a chest Xray is available and shows 👇🏻

Damnnnnn 😮😮😮

What's that ??

#MedTwitter

2/18

That is a massive mass in the neck and the mediastinum, also B/L CP angles are blunted 😮😮

This looks like a malignancy l/t superior vena cava (SVC) syndrome!

This is a medical emergency and you must know what next to do before the oncologist gets there!

#MedTwitter

3/18

Read 19 tweets

𝗡𝗶𝗵𝗮𝗿 𝗗𝗲𝘀𝗮𝗶

@nihardesai7

Jan 24

You are a young #medicine resident!

You are working in a heavy emergency when:
23,♂️,p/w acute breathlessness
You check his SpO2, it's👇🏻

You are worried and start him on supplemental 02, but he remains hypoxic😭

Read on for the diagnosis and a brief review!

1/20

#MedTwitter

Let's start with the causes of hypoxic that don't respond to supplemental oxygen !

🔸R➡️L cardiac shunts
🔸Methemoglobinemia
🔸Sulfmethemoglobinemia

The ABG that you sent is back!!

It shows a normal Pa02 but your pulse oximeter is still reading 85% 🤷‍♂️

2/20
#MedTwitter

Your registrar is smart and he asks you to send another sample, this time asking the lab for a methemoglobin value.

Voila !!

The lab says: 45% methemoglobin 😮

3/20

#MedTwitter

Read 20 tweets

𝗡𝗶𝗵𝗮𝗿 𝗗𝗲𝘀𝗮𝗶

@nihardesai7

Dec 13, 2022

As a #medicine resident you'll come across 👇🏻 scenario often.

Your #surgery colleagues want you to opine on the type and duration of ANTICOAGULATION and also want to know why it occured in the first place🤷‍♂️

Let's dig deeper 👇🏻

1/24

#MedTwitter #DVT

Yeah, this is obviously a Deep Vein Thrombosis (DVT) !

It's fairly common, develops in about 1/1000 people 😮

Remember, DVT+PE = VTE

PE= pulm embolism
VTE= venous thromboembolism

⭐1/3 DVT develop PE⭐

The PE is what can lead to mortality!
Preventing PE is IMPORTANT 🙏🏻

2/24

DVT is not less of a monster !

Many w/ DVT will develop post thrombotic syndrome 😮 That's a lot of morbidity, leg pain, swelling, ulceration and all 😭

But
🔸Why does VTE occur ?
🔸Who's at risk of developing it ?
🔸Can we prevent it ?
🔸How does one treat it ?

3/24

Read 24 tweets

𝗡𝗶𝗵𝗮𝗿 𝗗𝗲𝘀𝗮𝗶

@nihardesai7

Dec 7, 2022

Hey #medicine residents !!

Let's talk a bit about #mucormycosis today, the monster fungus 😡

Horrible infection w/ an unreasonably high mortality (40-80%) 😭

Risk factors:
🔸DM
🔸Neutropenia
🔸Post-HSCT

DM- Rhino-orbito-cerebral mucor
Neutropenia- Pulmonary mucor

#MedTwitter

The disease is caused by fungi of the order "MUCORALES"

This includes rhizopus/mucor/licthemia/cunninghemela species 😮

DON'T WORRY species identification doesn't change treatment so we don't need to get to that 🙏🏻

#MedTwitter

Coming to the PRACTICAL POINTS that need to be remembered !

🔸Obtain IMAGING even at the slightest suspicion of mucor coz it's RAPIDLY PROGRESSIVE and kills quick.

🔸CT PNS/Orbits
🔸MRI Brain
🔸HRCT chest as per presentation

#MedTwitter

Read 10 tweets

𝗡𝗶𝗵𝗮𝗿 𝗗𝗲𝘀𝗮𝗶

@nihardesai7

Nov 10, 2022

If you are a #medicine resident you will be called by your colleague to consult on this topic 👇🏻

**𝐇𝐞𝐩𝐚𝐫𝐢𝐧 𝐈𝐧𝐝𝐮𝐜𝐞𝐝 𝐓𝐡𝐫𝐨𝐦𝐛𝐨𝐜𝐲𝐭𝐨𝐩𝐞𝐧𝐢𝐚**

If you wanna revise, read this thread 👇🏻

#MedTwitter

1/18

Let's get this right, you'll get a lot of consults for suspected HIT. Most of them won't turn out to be HIT but you must know what to do in case it is HIT !

Is every TCP in a patient receiving heparin, HIT?
NOOOO, obviously NOT

The incidence is <1% of all pts on heparin😮

2/18

Why is it so important to recognise it?

Because HIT is not simply thrombocytopenia 😮

It's TCP + THROMBOSIS.

That's bad, very bad !!

Can be limb or life threatening 😭😭

3/18

#MedTwitter