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Bleeding after anticoagulation

3K views 20 replies 10 participants last post by  Doctor Ali 
#1 ·
52 year old man with history of deep vein thrombosis is in the hospital, preparing for a routine surgical procedure next day. He has been taking an oral anticoagulant for the past 5 years. On arrival at the hospital, he is switched to an intravenously administered drug for the duration of his stay. In the morning of his surgery, he awakens to find large bruises covering his arms and legs and blood oozing from his gums. A full blood panel reveals bleeding time of 5 minutes, PTT of 150 seconds, and PT of 12 seconds. If this patient had had this presentation 5 - 7 days after the onset of his intravenous drug therapy, what medication could be given to help treat his condition?

A. Fresh frozen plasma
B. Vitamin K
C. Heparin
D. Protamine Sulfate
E. Lepirudin
F. tPA
G. Warfarin
 
#8 ·
I think the ans is A. Fresh frozen plasma, because it dates less than 24 hours, still contains all clothing factors as well as platelets, and could thus solve the coagulation defect
Isn't fresh prozen plasma used for the fast reversal of Heparin overdose and Warfarin is not given IV, but Orally.

I think the question is asking about the drug which would be given IV,and heparin is the one which is injected IV.So to reverse the toxicity of Heparin , we would give Protamine to the patient.

I would go with D. Protamine Sulfate.:confused:
 
#16 · (Edited)
E

52 year old man with history of deep vein thrombosis is in the hospital, preparing for a routine surgical procedure next day. He has been taking an oral anticoagulant for the past 5 years. On arrival at the hospital, he is switched to an intravenously administered drug for the duration of his stay. In the morning of his surgery, he awakens to find large bruises covering his arms and legs and blood oozing from his gums. A full blood panel reveals bleeding time of 5 minutes, PTT of 150 seconds, and PT of 12 seconds. If this patient had had this presentation 5 - 7 days after the onset of his intravenous drug therapy, what medication could be given to help treat his condition?[/FONT][/SIZE]

E. Lepirudin

It is not inhibited by PF4 therefore successful in treatment of HIT.
:confused:
 
#17 ·
Correct answer is Lepirudin

Let's break this up.

1. This man has DVT and has taken oral anticoagulants for past 5 years. Most likely Warfarin in this case.

2. Upon hospital, he is SWITCHED to IV. This has to be Heparin because again he has history of DVT.

3. In the morning, there were bruises all over. Then the staff members did the blood test for this guy and saw what happen/why he was in bruises.

4. Lab values: bleeding time normal, PT normal, PTT increased.
Here, we can get rid of Fresh frozen plasma, and Vitamin K. Why? Because his PT is normal and he's not on Warfarin either because he was SWITCHED from Warfarin to Heparin.

5. His PTT is increased, indicating that he's on Heparin. Now you won't want to give Heparin to Heparin overdose, right? So we can get rid of heparin. tPA itself has no business here so we can get rid of that as well.

6. Now we are left with Protamine Sulfate and Lepirudin.

We see that this patient has increased PTT which is caused by Heparin overdose. Therefore, you would give Protamine Sulfate. But this is not the entire case. The question itself is asking:
If this patient had had this presentation 5 - 7 days AFTER THE ONSET of his intravenous drug therapy, what medication could be given to help treat his condition?

In other words, this patient has Heparin overdose + something else as of right now; what he will present in 5 - 7 days later?

Ladies and gentlemen, this patient has Heparin overdose due increased PTT and he finds large bruises covering his arms and legs and blood oozing from his gum. Put them together and these are symptoms of thrombocytopenia. As the time goes by, he will eventually develop Heparin Induced Thrombocytopenia. Had this patient presented with symptoms of Thrombocytopenia 5 - 7 days after the initial IV Heparin treatment, he would be suffering from development of Heparin Induced Thrombocytopenia. Heparin Induced Thrombocytopenia predisposes to thrombosis and exacerbate previously diagnosed blood clot. But still why Heparin Induced Thrombocytopenia? Recall that when he woke up he finds large bruises covering his arms and legs and blood oozing from his gum.

The treatment here therefore, would be Lepirudin.
 
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