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EMEDPA

EM Challenges, Episode #1

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The pt who both needs to be anticoagulated(say multiple PEs)  and bleeds whenever they are.

discuss. Had one the other day. Hospitalist said" I hate the bleeding clotters".

strategies?

Example: 85 yr old woman on coumadin with goal INR of 2.0 for multiple PEs. Frequent GI bleeds requiring transfusion. Obviously coumadin reversed for each episode then again uptitrated, then pt rebleeds.

GO!

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Still lots of questions. Are we assuming she is high risk, such as unprovoked DVT, and REQUIRES persistent anticoagulation, or are we having a discussion about whether or not to resume anticoagulation?

Further are we assuming she will probably always rebleed, such as high risk fact of GI telangiectasias?

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1 hour ago, Eastcoast PA-C said:

Sounds like someone needs an IVC filter.


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considered and rejected. "pt is not a good surgical candidate due to her comorbidities".

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Just now, LT_Oneal_PAC said:

Still lots of questions. Are we assuming she is high risk, such as unprovoked DVT, and REQUIRES persistent anticoagulation, or are we having a discussion about whether or not to resume anticoagulation?

multiple DVTs and PEs every time she goes off anticoagulation. 3 GI bleeds just in the last 2 months requiring transfusion. DNR/DNI, but short of a code wants everything done.

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They never find anything on scope? Tagged RBC? Part of the problem is probably given vit K, given a crap ton of coumadin to overcome it, then suddenly supratherapeutic. Nobody wants to be the person that gives a wimpy dose of vitamin K because legally speaking you are statistically less likely to be sued for doing something than not, unfortunately.  Xa inhibitors have decreased risk of major bleeding. We have andexa now for reversal of Xa inhibitors, but that puppy costs 50k for a dose. Honestly haven't encountered this yet. Might ask IR if they would place a filter. 

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She’s not a candidate for a minimally invasive procedure that wouldn’t require anesthesia? That’s some seriously poor protoplasm right there.

Fun case!

My lazy answer would be to call hematology and do whatever they tell me.

The non-lazy answer would be that we are in need of anticoagulation that is reversible, and hopefully avoid big fluctuations in clotting/thinning. So my ideas are:
1. Heparin Sub-Q
2. Pradaxa
3. Daily INR tracking with home testing and hope for the best.
4. Hate to sound defeatist, but ave a solid conversation with the patient to lay out just what a predicament we are in. If she’s alternating between massive GI bleeding and thromboembolism, and is too sick for an IVC filter...this sounds like someone who doesn’t have long to live and may benefit from talking to palliative care to lay out all the options.

I’m interested to hear what you all decided to do.


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will update when I hear the final decision. scopes from above and below negative. I think they are leaning towards alternate anticoagulation regimens in lieu of warfarin. last time I saw her they had just restarted coumadin and her INR was not even therapeutic yet, it was 1.7 and she was bleeding...

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Just curious, what was their reasoning for declining to do an IVC filter if someone was willing to go through the sedation and prep necessary for EGD and colonoscopy?


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18 hours ago, EMEDPA said:

The pt who both needs to be anticoagulated(say multiple PEs)  and bleeds whenever they are.

discuss. Had one the other day. Hospitalist said" I hate the bleeding clotters".

strategies?

Example: 85 yr old woman on coumadin with goal INR of 2.0 for multiple PEs. Frequent GI bleeds requiring transfusion. Obviously coumadin reversed for each episode then again uptitrated, then pt rebleeds.

GO!

Nobody has given the correct emergency medicine treatment plan yet?

-Stabilize, then admit to medicine    😉

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17 hours ago, Eastcoast PA-C said:

Just curious, what was their reasoning for declining to do an IVC filter if someone was willing to go through the sedation and prep necessary for EGD and colonoscopy?


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the scopes were a while ago (done together) and there were complications.

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16 hours ago, ohiovolffemtp said:

1. Punt to HemeOnc.

2. Has this patient ever tried any of the NOAC's?

This is the direction they are going I think...

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Episode #2: we have all seen this pt, probably at least once/month...

The afebrile/well hydrated pt with a nl cxr and possible PE with elevated d-dimer, pleuritic CP, and tachycardia who you can't do a CTA on due to poor renal function at a facility without nuc med capability. Lets assume b/l lower ext u/s neg for dvt and nl trops.

do you:

transfer for nuc med study or pulmonary angiogram?

anticoagulate and assume PE? (have done this twice recently. once it was the right thing to do, once it was not...)

your hospitalist refuses to admit without a definitive dx.

discuss. assume rural critical access hospital with minimal services available on site.

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3 hours ago, EMEDPA said:

Episode #2: we have all seen this pt, probably at least once/month...

The afebrile/well hydrated pt with a nl cxr and possible PE with elevated d-dimer, pleuritic CP, and tachycardia who you can't do a CTA on due to poor renal function at a facility without nuc med capability. Lets assume b/l lower ext u/s neg for dvt and nl trops.

do you:

transfer for nuc med study or pulmonary angiogram?

anticoagulate and assume PE? (have done this twice recently. once it was the right thing to do, once it was not...)

your hospitalist refuses to admit without a definitive dx.

discuss. assume rural critical access hospital with minimal services available on site.

I hate NM studies for PE. Getting a report that says pt has a "low probability" of PE is not reassuring to me if I'm concerned enough to order imaging in the first place. 

EKG/POCUS to look for right heart strain....if present, would certainly help build a case for PE.

If hospitalist still refuses to admit, I would transfer the patient elsewhere. If this patient has CKD, I'm assuming they have other co-morbidities too, which would likely make them a poor candidate for outpatient management. And if they're going to be admitted anyway, they  might as well be admitted someplace with the resources available to further assess the suspected problem. 

Interested to see what others would do. 

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I'd transfer probably ED => ED, for a VQ scan or whatever study the accepting doc would like.  Depending on my gut feel and the length of the transport, I'd give a shot of Lovenox prior to transfer.   My goal would be to make sure the patient went to a place where further evaluation was going to happen.

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On 1/31/2019 at 2:47 PM, EMEDPA said:

This is the direction they are going I think...

#1:  Years ago the correct answer would’ve been “find the cancer” with a DVT/PE since there was a reported 30% likelihood that this was the source of the bleeding dyscrasia.  Now they seem to have backed off this percentage somewhat.  Sounds like someone needs to check the clotting cascades and make sure the liver is happy.  Personally, I’ll take my chances with the clots as opposed to bleeding out.

Edited by GetMeOuttaThisMess

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Love these cases!  Keep them coming.  

 

My basic thoughts on case 2 would be to transfer, but if for the purposes of discussion that weren't an option or if it came back indeterminate, next step would be bedside echo for all of the fancy things they're now looking for suggesting PE / right heart strain.  Lets say its another patient like in case 1 who is a high risk for starting anticoagulant and you want to be absolutely sure before you anticoagulate, would it be crazy to just do the CTA?  If the risks of starting anticoagulation / bleeding outweigh the probably overstated risk of contrast induced permanent ESRD (the only real outcome we care about), then we take the less riskier option of the two and scan them.  Could maybe get nephrology input, or do shared decision making with the patient.

In an episode of emrap, I think, they had a similar discussion, stemming from the question "if you have a high suspicion for dissection, why the heck are you waiting for the creatinine to come back?  Get them to CTA now!"  There are two possibilities: the creatinine comes back normal and you can get the CT without issues, or the creatinine comes back very elevated suggesting even higher pretest suspicion for dissection because it is now knocking out the kidneys meaning you need the CT all the more.  In both situations you need the CT, so just forget the creatinine and send them asap.  

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46 minutes ago, SERENITY NOW said:

Love these cases!  Keep them coming.  

 

My basic thoughts on case 2 would be to transfer, but if for the purposes of discussion that weren't an option or if it came back indeterminate, next step would be bedside echo for all of the fancy things they're now looking for suggesting PE / right heart strain.  Lets say its another patient like in case 1 who is a high risk for starting anticoagulant and you want to be absolutely sure before you anticoagulate, would it be crazy to just do the CTA?  If the risks of starting anticoagulation / bleeding outweigh the probably overstated risk of contrast induced permanent ESRD (the only real outcome we care about), then we take the less riskier option of the two and scan them.  Could maybe get nephrology input, or do shared decision making with the patient.

In an episode of emrap, I think, they had a similar discussion, stemming from the question "if you have a high suspicion for dissection, why the heck are you waiting for the creatinine to come back?  Get them to CTA now!"  There are two possibilities: the creatinine comes back normal and you can get the CT without issues, or the creatinine comes back very elevated suggesting even higher pretest suspicion for dissection because it is now knocking out the kidneys meaning you need the CT all the more.  In both situations you need the CT, so just forget the creatinine and send them asap.  

Or three, the dissection isn’t there, you blow out the kidneys, and now they’re on dialysis.  Just playing devil’s advocate.  It’s a no win situation unless you find a dissection, repair, and the kidneys survive.

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True, but that would be easy to defend since the test would still have been clearly indicated.  With a high pretest suspicion for dissection and you get an elevated creatinine back, CT is still indicated / recommended by experts.  The risk of dissection is huge, and risk of CIN progressing to ESRD is extremely unlikely.  

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