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69 Posts
Discussion Starter · #1 ·
A 62-year-old woman presents with worsening abdominal pain that started 16 hours ago. Since then, she has vomited 2 times. Now the pain is localized in the right lower quadrant (RLQ). Her past medical history is remarkable for mitral valve replacement 8 years ago, because of rheumatic heart disease. She is on warfarin therapy. Abdomen is soft, nondistended, and tender with rebound in the RLQ. Psoas sign is positive. Bowel sounds are diminished. Her Temperature is: 37.4C(99.4F), axillary and 38.2C(100.9F), rectally. Upright abdominal x-ray is normal. Ultrasound is positive for several stones in the gall bladder.

Laboratory is:
WBC 17,700cmm
Hb 10.8
PT 32 sec
INR 2.5
Platelet count 120,000
The next step of the management should be?
A. Start antibiotics and vitamin K
B. Infuse protamine sulfate
C. Infuse fresh frozen plasma
D. Start heparin in prophylactic dose
E. Perform laparotomy

· Registered
187 Posts
The dilemma here is whether to perform appendectomy in a patient on chronic anticoagulation regime. Although warfarin interferes with the vitamin K pathway, administration of vit-K should take time to act, which in not a plausible option in this setting. So I would agree with dr.FSUSTC and go for FFP (which acts much faster than Vit-K by readily replenishing the inactivated clotting factors) before rushing the pt to the OR.
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