Month: January 2016

Neurocritical Care Society and Society for Critical Care Medicine recommendations for reversal of antithrombotic agents in patients with intracranial hemorrhage

Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage : A Statement for Healthcare Professionals from the Neurocritical Care Society… – PubMed – NCBI http://www.ncbi.nlm.nih.gov/pubmed/26714677

Here’s my breakdown of Table V from that article – I will try to find a way to post a downloadable PDF of this!

Antithrombotic: Timing, Antidote, Factor Replacement, antifibrinolytics

Vitamin K antagonists (warfarin) If INR > 1.3 then Vitamin K 10 mg IV, plus 3 or 4 factor PCC IV

(dosing based on weight, INR and PCC type) OR FFP 10–15 ml/kg IV if PCC not available

Direct factor Xa inhibitors: activated charcoal (50 g) within 2 h of ingestion, activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV

Direct thrombin inhibitors (dabigatran): Activated charcoal (50 g) within 2 h of ingestion, AND Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV                                                                Idarucizumab 5 g IV (in two 2.5 g/50 mL vials) consider hemodialysis or idarucizumab redosing for refractory bleeding after initial administration if 1) dabigatran was taken with 3-5 half lives and NO evidence of renal insufficiency or 2) dabigatran was taken beyond 3-5 half lives WITH renal insufficiency

For other DTIs: Activated PCC (FEIBA) 50 units/kg IV OR 4 factor PCC 50 units/kg IV

Unfractionated heparin: Protamine 1 mg IV for every 100 units of heparin administered in the previous 2–3 h (up to 50 mg in a single dose)

LMWH

Enoxaparin: Dosed within 8 h: Protamine 1 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) Dosed within 8–12 h: Protamine 0.5 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose)       Minimal utility in reversal >12 h from dosing

Dalteparin, Nadroparin and Tinzaparin: Dosed within 3–5 half-lives of LMWH: Protamine 1 mg IV per 100 anti-Xa units of LMWH (up to 50 mg in a single dose) OR rFVIIa 90 mcg/kg IV if protamine is contraindicated

Danaparoid: rFVIIa 90 mcg/kg IV

Pentasaccharides: Activated PCC (FEIBA) 20 units/kg IV or rFVIIa 90 mcg/kg IV

Thrombolytic agents (plasminogen activators): Cryoprecipitate 10 units IV OR antifibrinolytics (tranexamic acid 10–15 mg/kg IV over 20 min or e-aminocaproic acid 4–5 g IV) if cryoprecipitate is contraindicated

Antiplatelet agents: DDAVP 0.4 mcg/kg x 1, if neurosurgical intervention, transfuse one apheresis unit

I am joined by Tony Mazzeo MD, Chairman of Emergency Medicine at Mercy Catholic Medical Center and Vice Chairman of Mercy Operations for me here at Drexel Emergency Medicine. Tony and I tackle the ever important concept of efficiency and try to distill it down to some basic tips. Here’s the Hot Stove Tips:

1) empty the beds
2) Start with the dispo in mind (leave the room with a plan) and identify blockers
3) measure and track your throughput
4) anticipate problems
5)process in parallel and not in serial

Hope you enjoy it and let me know if you agree or have other great ideas!!!

 

Changes ahead in pregnancy labeling that will eliminate the ABCDX categories and supplant them with evidence specific information. Get ready/comfortable with understanding the risks of drugs for your patients and communicating that risk appropriately. Many of your former category B drugs may have risks (acetaminophen, ondansetron) and you may not be prescribing the safest drugs available – e.g. pyridoxine/doxylamine combination is the safest out there for morning sickness. But wait – isn’t that Bendectin, listen on to find out more…