One for the primary care folks

[EMEDPA]

Please, please, please primary care folks...when you start someone on a real anticoagulant have the talk with them about no ladders, bikes, skateboards, martial arts, insert activity with likelihood of head injury here, etc

This pt, who I have every reason to believe is dead now, was seen not once, but twice, by me for issues related to bleeding. 1st time they (pcp) switched pt from warfarin to xarelto after significant bleed following minor elective surgery. this recent injury was from performing a common recreational activity with the grand kids that someone should have warned them about. Did everything possible at my little critical access hospital: kcentra, hypertonic saline, mannitol,  intubation, lifeflight transfer to local trauma center with neurosurg, etc. They had a blown pupil by the time lifeflight arrived, this was totally preventable with a bit of education damn it.

[marktheshark89]

Deifinitely important to have this talk with them. I tell them they could die if they hit their head, fall, etc, but unfortunately many don’t listen. 

[EMEDPA]

so apparently there is a new reversal agent specific to xarelto and elliquis that was fda approved last month called andexxa. We have KCentra and Praxbind(for dabigatran/pradaxxa), but don't have this one yet. Pt above was on xarelto. 

[marktheshark89]

Yep I heard that also. The problem with it though is that it can induce a hypercoagulable state because of its mechanism unlike praxbind which is targeted to the pradaxa molecule. It also has only been tested in healthy patients, for ethical reasons, not those who were actually bleeding out, so now they have to do post marketing studies to see if it actually clinically improves outcomes. My guess is that your patient was probably beyond repair when he got to you, but definitely would have been nice to have to atleast try.