WARFARIN REVERSAL – When and How?

10 Jul
submitted by Amit Kumar, M.D. 
 
SERIOUS LIFE-THREATENING BLEEDING:
-Hold warfarin
-Vit K 10mg IV infusion over 20-60minsholygrail018
-PCC. Dosing based on weight and INR. Typical for INR >6: 50 U/kg. Re-check INR 30 mins post-admin.
-Transfusions: RBC, Platelets (if <50,000), FFP (15-30cc/kg; if PCC unavailable)
-Other agents: TXA/aminocaproic acid (anti-fibrinolytic), DDAVP (for platelet dysfunction)
 
URGENT SURGERY/PROCEDURE:
-Hold warfarin. Vit K + PCC, as above
 
SURGERY/PROCEDURE after 24H:
-Hold warfarin. Vit K 1-2mg
 
MINIMAL BLEEDING:
-Clinical judgement: withhold warfarin vs hold warfarin + Vit K vs more aggressive reversal (like above)
-Weigh pros/cons of current bleeding vs thromboembolic risk
 
NO BLEEDING:
-INR >9:  Vit K 2.5-5mg PO. Will reduce INR over 24-48 h. Can re-start warfarin (maybe reduced dose) when INR therapeutic
-INR 5-9: Hold warfarin temporarily (1-2 doses) +/- Vit K 1-2.5mg (elderly with slower clearance, prior bleeding)
-INR <5: Hold next dose of warfarin
 
SUPERWARFARIN POISONING:
-Often found in rodenticides, laced street-drugs. Accidental vs suicide attempt.
-Usually requires massive doses of Vit K (50-800mg/d) for months-years, based on repeat assays and coagulation studies
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PCC pearls:
-If 4-factor PCC missing, use 3-factor PCC + FFP (to supplement factor VII)
-PCC dose based on units of factor IX activity
-PCC advantage over FFP: more rapid admin (doesn’t have to be thawed), faster INR reversal, lower risks for volume overload or TRALI
 
References:
“Paper Chase 1- PCC vs. FFP.” Review. Audio blog post. Www.emrap.org. EM:RAP, Dec. 2013. Web. <https://www.emrap.org/episode/december2013/paperchase1pcc>. Episode 147
 
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DKA & HHS – treatment myths busted

26 Jun

submitted by Amit Kumar, M.D.

MYTH BUSTING:

*ABG >VBG: False, ABG = VBG.

Additionally, VBG is less painful and avoids complications like radial artery aneurysms, hematoma, and radial neuropathy. Lactate on VBG is equally reliable despite length of tourniquet time or temperature. pH of VBG is assumed to be 0.03 less than ABG. Only level missing in VBG are PaO2 and SpO2 (for which we have the pulse-ox). In general, ABGs are only useful in patient where knowing PaO2 is vital, and A-a gradient is desired.

 

*Shotgun insulin order s/p IVF: False. Correcting electrolytes is higher priority.

Serum K is low to begin with due to acidosis. Additional insulin and IVF will shift more K into cells, further depleting serum K. If K <3.5, replete K and hold insulin. If K 3.5-5.5, replete K with insulin. If K >5.5, may just give insulin.
fig04

 

*Insulin bolus, then drip: False.  Pediatric guidelines actually do not recommend bolus for potential risk for hypercorrection of serum glucose and cerebral edema.

Hypoglycemia is worse than hyperglycemia for mortality. So why do it? Per comparison studies, gtt at 0.14U/kg/h is better at providing a good therapeutic plateau, compared to 0.1U/kg bolus followed by 0.1U/kg/h gtt.
Replete Phos <1 mg/dL (vital for generating ATP) and Mg <2. Monitor Ca as well.

 

*HCO3 for pH <7.1: False. Bicarbonate exacerbates hypokalemia, and may even potentially increase risk of cerebral edema.

Bicarb also shifts O2 dissociation curve leftward, inducing hypoxia in a state of high demand. If given, just start a drip sans bolus, and mix with D5W (mixing with NS will cause precipitation and make solution hypertonic).

 

References:

*Kitabchi AE, Hirsch IB, Emmett M. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. In: UpToDate (Accessed on July 27, 2016)

*Swaminathan A, Herbert M. (2013, May). DKA Myths [Audio podcast]. Retrieved from: emrap.org

*Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider J, Sharieff GQ. Harwood Nuss’ Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

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DENTAL BLOCKS (quick procedure review)

19 Jun

submitted by Amit Kumar, M.D.

Easy procedures providing big-time opioid-free relief!

Can mix 50-50 lido and bupivacaine for quicker onset + longer analgesia combo.

Infraorbital nerve block:Infraorbital 1

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Retract cheek, insert needle next to 2nd premolar, 0.5cm from buccal surface. Advance parallel to tooth

3) You’ll palpate it next to foramen (under palpating finger) at depth of approx 2.5cm

4) Confirm location, aspirate, then inject 2-3 cc local anesthesia

5) Massage tissue for 15 secs to hasten onset

*Intraoral approach provides nearly 2x duration of anesthesia compared to extra-oral approach

 

 

 

 

 

 

Infraalveolar 1Inferior alveolar nerve block:

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Palpate coronoid notch with thumb, and stretch bucally (index & middle finger at angle of mandible outside)

3) Inject 2-3 cc of anesthesia at the site where middle of your thumb nail and pterygomandibular raphe biset

4) Massage tissue for 15 secs to hasten onset

*Will also anesthetize lingual nerve (anterior 2/3 of tongue in that side)

*Anesthetize long buccal nerve of that side, but injecting just distal and buccal to last molar

Reference(s):  Hedges, Jerris R., and James R. Roberts. Roberts and Hedges clinical procedures in emergency medicine. Philadelphia, PA: Elsevier Saunders, 2014. Print.

strength in numbers: blood transfusion risk

22 May

via a recent emdocs article (click through for the full read), some ballpark numbers that 190365-004-e1a439ccmight help you when you consent your next patient for a blood transfusion:

<1% (~0.63%) had a transfusion reaction, based on data from 2011

only 317/8,000,000 (~ 1 in 25,000) had a serious reaction requiring ICU-level care

risk of viral transmission:

  • HIV -> 1: 1,467,000 units
  • Hepatitis C -> 1: 1,149,000 units
  • Hepatitis B -> 1: 357,000 units

 

in comparison, for reference:

  • odds of a royal flush (5-card poker): ~1 in 650,000
  • odds of a four-of-a-kind (5-card poker): ~1 in 4000
  • odds (in a single year) of dying in a motor vehicle accident: ~1 in 9000
  • odds (in a single year) of dying in an “air and space transport” accident: ~1 in 770,000

 

References: emdocs article; poker probabilities; mortality risk

quick tip: easy fluorescein staining

28 Apr

via a recent post from the Procedural Pause:pp20fluoro20clinical20pearl

use a saline ‘bullet’ (dropper), drip a little saline on the fluorescein strip, then draw it back up.

 

handy for peds, or for squirmy adults, too

 

 

I’ve also seen the strip dropped in the back of a 10 cc syringe, or a saline flush used similarly as with the dropper above (see this ALiEM post for more).

dab-650x464

 

There you go. Add it to the toolbox.

 

References: procedural pause post, ALiEM post

 

 

vomiting during intubation? tube the esophagus

13 Apr

quick handy tip from this EMCRIT podcast for a vomit (or blood) laden oropharynx during intubation:jan_08_jems_intubation101

blindly (since you can’t see anything) insert an ETT; if it happens to be tracheal, great.

more likely, it’ll be in the (esopha)gUs.  LEAVE IT THERE.  you can intubate around it shortly, and you now have a landmark to intubate over. 

now here’s the tip: INFLATE the cuff on the esophageal ETT.  Also remember to tilt the now vomit-spewing ETT to the side, but this is now an outlet for the blood/vomit that won’t obscure your DL view

now, suction, and intubate the trachea.

 

Easy concept, handy tip.  Add it to the toolbox.

(check out the podcast for some more tips, but I thought that was the handiest).

 

References: EMCRIT podcast; picture

Torticollis (quick review)

21 Mar

submitted by Christina Brown, M.D. 

 

Definition – “Twisted neck” (L. tortus, twisted + collum, neck).29727

Synonyms: Cervical dystonia, wry neck

Self-limited, symptoms resolve in 1 to 2 weeks

Possible Etiologies:

  • Fracture
  • Dislocation, subluxation
  • Cervical spine disease
  • Infections
  • Spondylosis
  • Tumor
  • Scar tissue–producing injuries
  • Ligamentous laxity in atlantoaxial region
  • Drug induced
  • Otolaryngologic:
    • Vestibular dysfunction, Otitis media
    • Cervical adenitis, Pharyngitis, Retropharyngeal abscess
    • Mastoiditis
  • Esophageal reflux
  • Syrinx with spinal cord tumor

 

Physical Exam

  • Intermittent painful spasms of sternocleidomastoid (SCM), trapezius, and other neck muscles
  • Head is rotated and twisted to one direction

 

Management:

Imaging

  • Plain film if cervical fracture is suspected.
  • CT or MRI of cervical spine if retropharyngeal abscess or tumor suspected

INITIAL STABILIZATION/THERAPY: Cervical spine immobilization if fracture is suspected

ED TREATMENT/PROCEDURES

  • Soft collar and rest,
  • Physical therapy,
  • Massage,
  • Local heat,
  • Analgesics

 

MEDICATION:

  • Diphenhydramine (for drug-related dystonia)
  • Valium: 2–5 mg IV, 2–10 mg PO t.i.d. (peds: 0.1–0.2 mg/kg per dose IV or PO q6h)
  • Botulinum toxin is an option for treating non-drug-induced torticollis, though this is not typically administered in the ED setting.

 

References:
1. Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). Torticollis. Rosen’s and Barken’s 5-Minute Emergency Medicine Consult. http://www.r2library.com.proxy.its.virginia.edu/Resource/Title/1608316300/ch0020s16613
2. Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol 1997; 111:1183.
3. Soundappan SV, Darwish B, Chaseling R. Traumatic spinal epidural hematoma-unusual cause of torticollis in a child. Pediatr Emerg Care 2005; 21:847.
4. Mutsaers P, Fick M, Plötz FB. Acquired torticollis as the only initially presenting symptom in a child with a brainstem glioma. Eur J Pediatr 2007; 166:1075.
5. Shanker V and Bressman S.: What’s new in dystonia? Curr Neurol Neurosci Rep. 2009; 9:278–284.

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