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Emergency Department Reversal Of Anticoagulation

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

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  1. 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

  2. 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

  3. 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

  4. You Are Working At A Small Rural Hospital INR = 3.1 What Next?

  5. The Stakes Are High! No Reversal Prior To Transfer

  6. ED Reversal Of Anticoagulation

  7. Atrial Fibrillation In The U.S. • Prevalence increases with age • 9% of adults >65 years old

  8. Dhakal P. Clin App Thrombosis & Hemostasis 2017. 23:410-415.

  9. Warfarin • Direct thrombin inhibitors • Factor Xa inhibitors • Platelet inhibitors • Unfractionated heparin • Low molecular weight heparin • Thrombolytic agents

  10. Warfarin • Direct thrombin inhibitors • Factor Xa inhibitors

  11. The Medical Letter March 2015. Volume 57 (Issue 1465).

  12. Vitamin K • Fresh frozen plasma • 4-Factor prothrombin complex concentrate • Idarucizumab • Andexanet alfa • Platelets • DDAVP • Cryoprecipitate

  13. Vitamin K • Fresh frozen plasma • 4-Factor prothrombin complex concentrate • Idarucizumab • Andexanet alfa

  14. 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]

  15. “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.

  16. Y Y No Yes Tomaselli GF. JACC 2017. 70:3046-63

  17. Y Y No Yes

  18. Frontera JA. Neurocritical Care 2016. 24:6-46.

  19. Frontera JA. Neurocritical Care 2016. 24:6-46.

  20. Intracerebral Bleeding “But The Patient Has A Mechanical Valve!!!” “But The Patient Has An LVAD!!!”

  21. ICH + Mechanical Heart Value

  22. “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]

  23. “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

  24. ICH + Left Ventricular Assist Devices

  25. “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.

  26. “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.

  27. What Next?

  28. Frontera JA. Neurocritical Care 2016. 24:6-46.

  29. 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

  30. 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).

  31. 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

  32. Fresh Frozen Plasma

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