Haem Emergencies - PowerPoint PPT Presentation

Loading...

PPT – Haem Emergencies PowerPoint presentation | free to download - id: 4f58dd-NjI2M



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Haem Emergencies

Description:

Haem Emergencies Nadim J Lalani MD July 24. 2008 * IC event rate? Management Don t forget other stuff: Stitches/direct pressure/local epinephrine If you don t ... – PowerPoint PPT presentation

Number of Views:79
Avg rating:3.0/5.0
Slides: 66
Provided by: NadimJ
Learn more at: http://calgaryem.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Haem Emergencies


1
Haem Emergencies
  • Nadim J Lalani MD
  • July 24. 2008

2
?
3
David Dwight Ike Eisenhower 1890-1969
  • Former general ? 34th US Pres (19531961). Served
    2 terms
  • Avid golfer ? Hcap of 18. Broke 80 3 times. Had 1
    hole in one.
  • Played 800 rounds in 8 years as President.
  • Was one of the 1st people on Coumadin
  • Parents were JWs

4
Ike Continued
  • Member at Augusta
  • Hated the Loblolly pine off the tee on the 17th
  • Petitioned to have it cut down.
  • Now named after him.

5
Objectives
  • Review hemostasis
  • Work through cases.
  • By the end, you should know how to manage
  • DIC
  • ITP
  • Hemophilia and V W dis
  • Coumadin and Heparin overanticoagulation
  • Complications of thrombolytic

6
Hemostasis Steps 1 and 2
  • Vessel constriction
  • Primary Hemostasis
  • ?exposed collagen
  • ? VWf attaches
  • ? gathers plts and fibrinogen platelet plug
  • Mucocutaneous bleed

7
Clotting Step 3
  • Secondary Hemostasis
  • ? Clotting Factors
  • Factor VII extrinsic gets used up quick
  • Intrinsic PTT, Extrinsic PT
  • Prothrombin ? thrombin
  • fibrinogen ? fibrin

8
Clotting Cascade
9
Step 4 Breakdown
  • Plasminogen ? Plasmin
  • Fibrin ? FDPs

10
Case 1
  • 4 yo F brought in by parents for this rash.
  • URTI 2 weeks ago

11
Case 1 petechiae
  • ?(muco)Cutaneous
  • ? Pinpoint dots of blood.
  • ? DONT Blanch
  • ?Larger flat areas purpura.
  • ?Very large area ecchymosis.

NB most common cause of petechiae in kids is
prolonged/persistent valsalvas ie coughing ...
See it in upper torso SVC distribution.
12
Platelet problems
Too Few
Dont Work
Decreased Production
Sequestration
ASA, plavix rena and hepatic disease, vWD
Destruction
Immune
Non-immune
splenomegaly
TTP DIC HELLP Sepsis
ItP
Marrow failure
Dr. A. Oster
13
ITP
  • What?
  • ? Autoantibodies cause thrombocytopenia
  • Who?
  • ?Children 2-6, MF
  • Pathophys IgG usually against membrane GPs (75
    anti-Giib/iiia) ?spleen eats up plts
  • Features preceded by viral illness 3 weeks
    before onset, 1 CNS bleed, 10 other signif
    bleed, almost no mortality
  • LAB
  • ?Plts usually lt20 can have anemia

14
ITP Treatment No consensus
Idiopathic Thrombocytopenic Purpura A Practice
Guideline Developed by Explicit Methods for The
American Society of Hematology By James N.
George, Steven H. Woolf, Gary E. Raskob, Jeffrey
S. Wasser, Louis M. Aledort, Penny J. Ballem,
et.al
  • Platelets gt 30,000/mL ?No Tx. Outpatient f/u
  • Platelets lt 20,000/mL ? PO steroids /- IVIG
    /- admit.
  • Platelets lt 10,000/mL or signif bleeding. IV
    steroids/ IVIG high dose better? admit

15
  • Transfusions anyone?
  • Only if severe bleeding
  • Adults look for other causes esp gt 60 yo
    cancer/myelodysplasia
  • ASH Guidelines for Adults confusing
  • Plts gt 50,000 NO Rx unless signif bleed or risk
    factors htn/pud
  • Plts gt 30,000 and asympt ? NO IVIG
  • Plts 20,000 and asymptomatic/mild purpura ?NO
    admit
  • Plts 20,000 30,000 and bleeding? Treat
    steroids appropriate
  • Plts ,20,000 ? treat and admit

16
  • Rhogam? Works if Rh and is 1000 US cheaper
    than IVIG. 50mcg/kg
  • Increased Plt Count initially better IVIG vs
    Steroids/Anti D
  • Some argument for no treatment
  • Standard of care in N.Am / Calgary is
    IVIG/Steroids/admit

17
Case 2
  • 33 yo G2P1 _at_ 22 wks GA
  • Presents vomiting with abdominal pain and malaise
  • BP 150/90, 105, 20, sats 99
  • Jaundiced, tender RUQ
  • Labs
  • Hb 90, PLT 80, inc ALT/AST/bili
  • Coags normal
  • Ddx??
  • http//www.aafp.org/afp/990901ap/829.html

Dr A Oster
18
Case 3
  • 60M with ESRD comes in septic with this ?
  • During w/u note that INR and PTT up
  • What is going on?
  • Futher w/u?

19
DIC
  • complex systemic thrombohemorrhagic disorder
  • involving consumption of coag factors and
    platelets.
  • characterized by generalized bleeding
  • ranges from petechiae ? exsanguinating hemorrhage
  • Also get thrombosis.
  • Seen in 30-50 septic pts carries 20-50
    mortality

20
(No Transcript)
21
Table 1. Conditions underlying DIC syndrome
Infections Acute DIC Bacteria and their toxins, fungi, viruses, rickettsiae Chronic DIC Any chronic infection (eg, tuberculosis, abscesses, osteomyelitis) Noninfectious inflammatory diseases Inflammatory bowel disease Crohn's disease and similar disorders Obstetrical complications Acute DIC Abruptio placentae, abortions (especially therapeutic abortions), amniotic fluid embolism, hemorrhagic shock Chronic DIC Dead fetus syndrome Malignancy Acute DIC Acute promyelocytic leukemia, acute myelomonocytic or monocytic leukemia, disseminated prostatic carcinoma Chronic DIC Lung, breast, gastrointestinal malignancy Vascular disease Acute DIC Brain infarction or hemorrhage Chronic DIC Aortic aneurysm, giant hemangioma Venoms Acute DIC Snake, spider (rare) Trauma Acute DIC Massive tissue destruction, brain damage Others Acute DIC Heparin-induced thrombocytopenia with thrombosis (HITT), purpura fulminans in newborns (homozygous protein C deficiency)
22
Lab
  • Plt ?low
  • INR ?high
  • PTT ?high
  • FDP ?positive/high
  • Fibrinogen ? low
  • DIC D-Dimer ?positive

23
DIC Treatment
  • ABCs dont forget Calcium check ABG
  • Treat underlying cause
  • RBCs
  • Plts
  • Maintain gt30 or higher if OR planned
  • 1U plts contained 5x109 plt
  • expected to raise plasma by same
  • FFP
  • If DIC assoc with increased INR and PTT
  • Cryo
  • If fibrinogen lt2
  • Give 1-4U/10kg

24
AT III
DBRCT 2300 pts ATiii 30,ooo IU over 4 days vs
Placebo Outcomes 10 ? 28d mort 20 ? ICU stay,
50d mort No Difference , but trend in
No-heparin sub group
25
Publication of a sub group analysis
High-dose antithrombin III in the treatment of
severe sepsis in patients with a high risk of
death Efficacy and safety Wiedermann,,
et.al Critcal Care Medicine Volume
34(2), February 2006, pp 285-292
1000pts Better 90d survival with AT iii Even
better with no heparin 10 better survivial
26
 
Treatment effects of high-dose antithrombin
without oncomitant heparin in patients with
severe sepsis with or without disseminated
intravascular coagulation. Kienast J, Juers M,
Wiedermann CJ, Hoffmann JN, Ostermann H, Strauss
R, Keinecke HO, Warren BL, Opal SM J Thromb
Haemost. 2006 Jan4(1)90-7.
  • Another analysis of the same no heparin
    subgroup
  • Treatment with ATiii ? ARR 14

27
  • Subgroup analyis of PROWESS study
  • APC vs Placebo in pts with DIC
  • NO benefit and increased bleed risk

28
Other
  • Heparin benefit only in case reports NOT RCTs
  • Use if theombosis going on
  • Future Target TF pathway with TFPI / iFVIIa /
    rNAPc2 phase ii trials

29
Case 4
  • 7 mo girl Vomiting/lethargic/febrile
  • GM Sz in WR
  • O/E
  • Febrile/Tacchy w/ bulging fontanelle
  • lethargic
  • MGMT? Ddx?
  • LAB
  • Hb 60, PTT 90
  • LP RBCs and Xanthochromia
  • MGMT NOW Dr.?

30
Haemophilia
  • Two kinds
  • 88 Haemophilia A ? Factor VIII def
  • Haemo B aka Xmas ? Factor IX def
  • Haem A
  • X-linked recessive
  • 30 no family Hx 1/3 spontaneous mutation
  • Increased aPTT unless F Viii gt 30

31
Haemophilia
  • Classification based of percent factor
    activity
  • Mild ? gt5,
  • Moderate ? 1-5
  • Severe ? lt1
  • 80-90 present as hemarthrosis to the ED knee/
    elbow ? chronic haem dibilatating
  • MC cause of death in haemophilia? ICH ? low
    threshold to scan head treat prophylactically

32
Management
  • Depends of severity of bleed
  • Minor ? hemarthrosis/hematuria
  • Moderate ?GI bleed/epistaxis/dental
  • Severe ?CNS/airway/retroperitoneal
  • Haem A Haem B
  • 12.5 u/kg minor 25 u/kg
  • 25 u/kg moderate 25 u/kg
  • 50 u/kg severe 50 u/kg
  • Above regimen should raise FVIII levels to 25,
    50 and 100

33
Factor replacement
  • Each u/kg of Factor VIII increases factor levels
    by 2
  • Each u/kg of Factor IX increases factor levels by
    1

34
Management
  • Dont forget other stuff
  • Stitches/direct pressure/local epinephrine
  • If you dont know signif bleed assume factor
    activity is 0

35
What if no Factor?
  • Cryoprecipitate (2nd line)
  • Contains 100U FVIII (also contains vWF,
    fibrinogen, FXIII and fibronectin)
  • Dose 2bags/10kg to raise FVIII to hemostatic
    levels
  • T ½ 8hrs
  • Can give FFP
  • Contains all coagulation factors
  • Approx 7 of of all coag factor activity of a
    70kg person
  • DDAVP
  • Increases VWf
  • Good for mild cases

36
Case 5
  • 38 y m just had tooth pulled. Bleeding x6h
  • Hx easy bruising otherwise healthy
  • Father doesnt go to dentist for same
  • Ddx?

37
Von Willebrands Disease
  • Most common inherited bleeding dis 1 pop
  • AD but can be AR inheritance
  • Affects mostly primary hemostasis
  • VWf ? big protein
  • Binds platelets to collagen
  • Carries Factor Viii in blood

38
Von Willebrands
  • Three types
  • Type I 70-80 Less VWf therefore less F Viii
  • Type II abc 15-20 AD/AR Non-functional VWf
  • Type III absent VWf also affects F Viii
  • Tend to present with mucocutaneous bleeding
    except Type III

39
LABS
  • bleeding time? increased
  • Platelets? N
  • aPTT?/INR increased PTT, N INR
  • factor VIII level? Low
  • vWF antigen test
  • measures amount vWF
  • Mild ? 20 to 40
  • Severe ? lt 10
  • Ristocetin test? abnormal
  • How well the vWF is working

40
Treatment Options
  • Want 40-50 VwF activity for minor bleed
  • Want 80-100 for major bleeds should then be
    kept at gt50 for a week after
  • DDAVP
  • Increases vWf levels
  • If Pt is a responder NB! DDAVP Not enough for
    major bleeding
  • Dose IV ? 0.3 mcg/kg
  • IN Stimate ? 150 mcg 1 puff if lt
    50kg
  • 300 mcg gt 50kg
  • Dont use the DDAVP reserved for DI diluted

41
  • Humate-P
  • Specific vWF and factor VIII replacement
  • Each dose may vary in its vWf/FViii activity
  • Cryoprecipitate
  • No longer indicated unless dont have Humate
  • 1 bag contains approx 100U of vWF and FVIII
    (approx 10x more than FFP)
  • Non-R FViii?/FFP? Nope

42
Adjunct Drugs
  • Tranexamic acid (Cyclokapron)
  • an antifibrinolytic agent 10x more potent than
    Amicar
  • inhibits the activation of plasminogen ? plasmin.
  • Dose PO 25 mg/kg Q 6-8 IV 10mg/kg Q6-12
  • Clot risk / Not available
  • Epsilon amino caproic acid (Amicar)
  • Also Inhibits fibrinolysis
  • Dose 100 mg/kg/dose PO then 50mg/kg Q6
  • Topical thrombin and Fibrinogen
  • Estrogen?

43
Case 6
  • 60 yo with ACS
  • Got ASA, Heparin, bblocker
  • Waiting for CCU
  • Nurse asks you to see the pts rectal bleed
  • Mechanism of heparin
  • How do you reverse heparin?

44
Heparin
  • Unfractionated heparin
  • Major sites of activity ATIII, Xa
  • Other sites IIa, IXa, XIa
  • Anticoagulant effect largely through ATIII.
  • Produces a conformational change which
    accelerates the ability of ATIII to inactivate
    thrombin

45
(No Transcript)
46
How to reverse it?
  • Protamine
  • T ½ 60mins
  • 1mg protamine neutralizes 100 circulating units
    of UFH given in last 4h
  • Max 50 mg
  • Give slowly ? anaphylactiod rxn
  • NB! Include bolus

47
What about LMWH?
  • Inhibitor of Xa some ATIII action
  • Activity 14-16hrs, T ½ is 4hrs
  • Protamine can help but reversal is more difficult
  • lt 8h post-dose
  • Dose 1mg protamine 1mg Enoxaparin
  • gt 8h lt 12h
  • 0.5mg half dose 1mg
  • gt12h
  • Nothing

48
Case 7
  • 90 y F on warfarin sent in from LAB with INR of
    10
  • What do you do?

49
Coumadin
  • Vit K dependent coag factors
  • II, VII, IX, X
  • Cofactor in carboxylation of enzymes which
    activate factor
  • Ptn C and S
  • Measure INR
  • T ½ 2.5d

50
Who to reverse?
  • Life threatening
  • Have to ask why on warfarin
  • High risk 15/year stroke
  • Mechanical MV
  • AF with Valve dis
  • Low risk 1/1000 stroke
  • DVT
  • AF

51
EMrap treatment protocol
  • INR
  • lt5.0 no bleed ? skip dose
  • 5.0 9.0 no/minor bld ? hold 1mg VitK
  • 9 20 ? hold 3mg VitK
  • gt20 ? 10mg VitK FFP

52
Case 8
  • 82 y M. On coumadin for Mechanical AV
  • Falling to the Right. ? INR 4.4
  • Doctor?
  • Told to hold dose. Went home took nap. Awoke
    confused later in the Afternoon.
  • O/e GCs 14. Left weak. Left drift. Inc DTRs.
    Agnosia.
  • Doctor?

53
  • Doctor?

54
Prothrobin Complex
  • Octaplex 20ml vial of
  • Factors II, VII, IX X Proteins C and S

55
Octaplex
  • Indicated
  • Rapid Correction of VitK antagonists in the
    setting of
  • Major bleeding
  • Surgery imminent
  • Dose no more than 120ml

56
  • Well studied
  • Reversal in 15 min
  • Lasts 6 h
  • May cause thrombosis/allergy
  • Not tested in pregnant
  • Costs 500/vial. 2500 for max dose.

57
(No Transcript)
58
Case 9
  • 16 yo depressed swallowed a bunch of this
  • Doctor?

59
Brodifacoum Poisoning
  • Aka super coumadins
  • Half life?
  • 24-100 days
  • Treat as with Warfarin OAC
  • FFPs 15ml/kg in Peads
  • Requires 50-800mg/day of Vitamin K
  • Expect to treat for weeks/months

60
(No Transcript)
61
Vitamin K
  • Activated VitK hq
  • Catalyses carboxylation of
  • II,VII,IX,X, C, S
  • Oral takes 6h
  • IV takes 1h

62
Case
  • 60 with STEMI that youve thrombolyzed, now ALOc
    and you scan him

63
TPA
  • Converts plasminogen ? plasmin
  • Fibrin ? FDPs

64
Reversing lytics
  • Reversal
  • Stop lytic
  • Replenish fibrinogen
  • Cryo
  • FFP to correct prolonged bleeding time
  • PRBCs
  • Platelets
  • Reverse heparin

65
  • Absolute lytic contraindications
  • Hemorrhagic cerebrovascular accident
  • intracranial neoplasm
  • recent cranial surgery or trauma (10 days)
  • uncontrolled severe hypertension
  • Major surgery of thorax or abdomen (10 days)
  • prolonged cardiopulmonary resuscitation
  • current severe bleeding (e.g., gastrointestinal)
About PowerShow.com