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Emergency Department Reversal Of Anticoagulation. Michael Gibbs, MD, FACEP, FAAEM Professor And Chair Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Interim Vice President of Research. 2º Simposio Cardiovascular International 2019. Case Study.
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Emergency Department Reversal Of Anticoagulation Michael Gibbs, MD, FACEP, FAAEM Professor And Chair Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Interim Vice President of Research 2º Simposio Cardiovascular International 2019
Case Study A 67 year-old male slips and falls, striking his head. He complains of a headache and has vomited once. Medical History: hypertension, atrial fibrillation Medications: metoprolol, warfarin Allergies: none
Case Study ED Assessment Vitals:HR 65, BP 135/80, RR 16, GCS 15 Head:2 x 2 frontal scalp contusion without step-off Eyes: Equal pupils, normal eye movement Neck: Non-tender Chest: Lungs clear, chest non-tender Abd: Non-tender, no contusions MSK:Right knee abrasion, no evidence of fracture Neuro:A bit slow to respond, fluent speech, cranial nerves normal, No focal sensory loss or motor dysfunction
You Are Working At A Small Rural Hospital INR = 3.1 What Next?
The Stakes Are High! No Reversal Prior To Transfer
Atrial Fibrillation In The U.S. • Prevalence increases with age • 9% of adults >65 years old
Dhakal P. Clin App Thrombosis & Hemostasis 2017. 23:410-415.
Warfarin • Direct thrombin inhibitors • Factor Xa inhibitors • Platelet inhibitors • Unfractionated heparin • Low molecular weight heparin • Thrombolytic agents
Warfarin • Direct thrombin inhibitors • Factor Xa inhibitors
Vitamin K • Fresh frozen plasma • 4-Factor prothrombin complex concentrate • Idarucizumab • Andexanet alfa • Platelets • DDAVP • Cryoprecipitate
Vitamin K • Fresh frozen plasma • 4-Factor prothrombin complex concentrate • Idarucizumab • Andexanet alfa
Gather data as quickly as you can! • Problems that we have seen at CMC: • Anticoagulation not recognized • INR not ordered or delayed • Incorrect reversal agent given • Reversal agent reconstituted but not given [$5,000]
“2017 ACC Expert Consensus Decision Pathway on Management Of Bleeding In Patients On Oral Anticoagulants.” A Report of the ACC Task Force On Decision Pathways. Tomaselli GF. JACC 2017; 70:3042-63.
Y Y No Yes Tomaselli GF. JACC 2017. 70:3046-63
Y Y No Yes
Intracerebral Bleeding “But The Patient Has A Mechanical Valve!!!” “But The Patient Has An LVAD!!!”
“The Dilemma Of Discontinuation Of Anticoagulation Therapy For Patients With Intracranial Hemorrhage And Mechanical Heart Valves.” Wijdicks EF. Neurosurgery 1998; 42(4)769-73. • Design: • Single center retrospective review • 39 patient with intracerebral hemorrhage over a 20 year period • SDH [20], lobar [10], SAH [4], cerebellar [3], basal ganglia [2]
“Comparison Between PCC And FFP For The Urgent Reversal Of Warfarin In Patients With Mechanical Heart Valves.” Fariborz F. Iran J Pharm Res 2015; 14(3):877-85. • Design: • Warfarin reversed in 50 patients [1:1] for interventional procedures • Standard dosages of PCC and FFP
“Low-Dose Prothrombin Complex Concentrate in Patients with Left Ventricular Assist Devices.” Brown CS. ASAIO Journal 2018; ahead of print. “Low-Dose Prothrombin Complex Concentrate in Patients with Left Ventricular Assist Devices.” Rimsans J. J Thrombosis & Hemostasis. 2018; 46:180-185.
“Spontaneous Hemopericardium In A Patient Receiving Apixaban Therapy.” Sigawy C. Pharmacotherapy 2015. Epub, June 10. “Dabigatran-Induced Spontaneous Hemopericardium And Cardiac Tamponade.” Qurat-ul ain, J. Tex Heart Inst. 2017; 44(5):370-372. “Bleeding Heart: A Case Of Spontaneous Hemopericardium And Tamponade In A Patient On Warfarin.” Sajawal A. BMJ Case Reports. 2016; 1136/bcr-2016-215731.
Vitamin K (Phytonadione) • Necessary for the activation of factors II,VII, IX, X • In major bleeding administer 10 mg IV via slow infusion, repeated every 12 hours • Risk of anaphylaxis 3 per 10,000 doses
Pooled concentrate of factors II, VII, IX, X • Rapid reversal of the effects of warfarin • Weight/INR based dosing The Medical Letter July 2013. Volume 55 (Issue 1420).
Fresh Frozen Plasma • Plasma separated from blood, frozen within 8 hours • Contains all coagulation factors + albumen • Can be stored at [-] 30º C for up to one year • Once thawed, FFP is useable for 24 hours 4º C