Guideline: How To Manage Bleeding In The Anticoagulated Patient
Over the past year, I’ve written about bleeding problems in trauma patients caused or exacerbated by the various anticoagulants now on the market. The field of available drugs keeps growing, and the number of ways to keep blood in liquid form is increasing.
Here’s a link to a set of guidelines for approaching and treating patients who are taking these medications and then develop problematic bleeding. There are few good studies that have actually analyzed the efficacy of these methods, but it’s what we have to work with now.
If you have any additional maneuvers that you think should be included, please comment or email. And feel free to implement some studies to find the real best practices.
Link: Guideline for bleeding in patients taking anticoagulants
Anticoagulation Reversal In Trauma
I’ve previously written about reversing specific agents that may interfere with clotting in trauma patients. Today I’m going to provide a reference sheet to help you reverse any of the common agents that your trauma patients may be taking.
This reference is a work in progress and will change as new drugs are introduced. I’ll update it as revisions are made. And as always, comments and suggestions are welcome!
Click here to download the reference sheet.
Thanks to Colleen Morton MD from Regions Hospital for sharing this draft
Another Anticoagulant To Watch Out For
In May, I wrote about a new direct thrombin inhibitor named dabigatran (Pradaxa). This drug appears beneficial for patients who need ongoing anticoagulation without the hassle of blood testing to check drug levels. The danger for trauma patients is that there is no antidote or rapid reversal possible. This means that significant traumatic bleeding, particularly in and around the brain, cannot be stopped! At Regions Hospital, we have seen a few patients on this drug, but luckily they have not had bleeding from trauma.
Late last month, Bristol-Myers Squibb and Pfizer announced that a new drug has shown very favorable results in preventing strokes in patients with atrial fibrillation (apixaban, Eliquis). Indeed, it cut the relatively low risk of stroke in half, compared to warfarin. It also had about a third fewer bleeding complications. It looks like it may also give dabigatran a run for its money.
This drug is a Factor Xa inhibitor, and also has no antidote other than time. There is some evidence that activated charcoal given orally within 3 hours of apixaban dosing may be somewhat helpful in reducing blood concentrations.
Trauma professionals need to be on the lookout for patients who use this drug. Any trauma patient who admits to being on a “blood thinner” needs to be questioned carefully to determine which one it is. If it is one of the newer drugs without an antidote, they need to be monitored continuously for signs of bleeding (read: ICU), especially if they have experienced head trauma.
Bottom line: Be on the lookout for these drugs. If any patients who have fallen are taking this drug (elderly, frequently intoxicated, etc.), contact their primary physician so that the risks vs benefits of continuing it can be considered.