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A 68-year-old male with known aortic sclerosis was admitted with chest pain and ruled out for myocardial infarction but had recurrent symptoms during weaning from IV heparin and nitroglycerin over the ensuing 5 days. Cardiac catheterization revealed three-vessel disease with a normal ejection fraction, and he underwent coronary bypass grafting. On postoperative day 3 he complained of pain in the right arm and was found to have an absent right brachial pulse and a cold distal right arm. Laboratory work revealed a hematocrit of 38%, platelets 32,000, prothrombin time 15, INR 1.4, and partial thromboplastin time 65. What is the most likely explanation for this patient's absent brachial pulse? A. Left ventricular thrombus caused by a myocardial infarction with a subsequent brachial artery embolus B. Embolization from aortic sclerosis C. Embolization from paradoxical emboli through a patent foramen ovale from a deep venous thrombosis (DVT) arising postoperatively D. Thrombosis in situ caused by postoperative hypercoagulability E. Heparin-induced thrombocytopenia
achilles Forum Guru
Topics: 90 Posts: 1,228
06/17/06 - 07:40 PM
#2
A ___________________ " it's not whether you get knocked down, it's whether you get up" " i have miles to go before i sleep "
karusmle Forum Guru
Topics: 296 Posts: 1,001
06/17/06 - 11:28 PM
#3
answer id E , this is a question from kaplan Q bank
karusmle Forum Guru
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06/17/06 - 11:29 PM
#4
answer is E
AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/17/06 - 11:55 PM
#5
HIT ___________________ seeking study partner in USMLE, Canadian MCC OSCE examination
AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/17/06 - 11:57 PM
#6
HIT is a devastating prothrombotic disease HIT, which usually develops after a patient has been on heparin for 5 or more days, may develop sooner if there has been previous heparin exposure (see Figure 1).[3,14] Heparin binds to platelet factor 4 (PF4), forming a highly reactive antigenic complex on the surface of platelets and on endothelial cell surfaces, thereby increasing the number of targets for heparin-dependent antibodies.[3,14] Susceptible patients then develop an antibody (IgG) to the heparin-PF4 antigenic complex. Once produced, immunoglobulins, usually IgG, bind to the heparin-PF4 immune complex on the platelet surface. The Fc portion of the IgG then activates the platelets by binding to platelet Fc receptors.[3,14] Thrombocytopenia develops as the reticuloendothelial system consumes activated platelets, platelet microaggregates, and IgG-coated platelets.[3,14] Most devastating, however, is the thrombotic state that develops as a result of platelet activation and the generation of procoagulant microparticles, and an additional increase in thrombin generation.[3]
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AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:00 AM
#7
Heparin induced thrombocytopenia
HIT, which usually develops after a patient has been on heparin for 5 or more days as stated in this question the patient had been on heparin for 5 days or more !!! ___________________ seeking study partner in USMLE, Canadian MCC OSCE examination
AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:02 AM
#8
The mechanism opf HIT
Attached Files: 20_Fig1.gif (8 KB, 9 downloads) ___________________ seeking study partner in USMLE, Canadian MCC OSCE examination
AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:05 AM
#9
Table 2. Complications of HIT[7,10,18,26-29]
Deep vein thrombosis Pulmonary embolism Myocardial infarction Occlusion of limb arteries (possibly resulting in amputation) as in this case, the patient had pulseless right brachial pulse !!! Cerebrovascular accidents (stroke, TIA) Skin necrosis End-organ damage (e.g., adrenal, bowel, spleen, gallbladder or hepatic infarction; renal failure) Death
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AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:07 AM
#10
Treatment of HIT : Argatroban
Indications:[2] Argatroban is indicated as an anticoagulant for prophylaxis or treatment of thrombosis in patients with heparin-induced thrombocytopenia.
Argatroban is indicated as an anticoagulant in patients with or at risk for thrombocytopenia undergoing percutaneous coronary intervention (PCI). ___________________ seeking study partner in USMLE, Canadian MCC OSCE examination
AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:09 AM
#11
Administration of Argatroban Heparin-Induced Thrombocytopenia (HIT)[2] Initiate infusion of 2 mcg/kg/min
In hepatic impairment, initiate dose at 0.5 mcg/kg/min
Adjust to steady state aPTT of 1.5 to 3 x baseline
Usually 150 mcg/min, check the aPTT from 1.5 to 3x of baseline
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AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:11 AM
#12
What is Argatroban used for?
Antidote for HIT !!
Argatroban is used to treat and reduce the risk of blood clots in patients who have had a reaction to heparin that resulted in reduced platelets and associated blood clots.
Argatroban is also used in patients undergoing certain heart procedures such as percutaneous coronary interventions (PCI) who are at risk or have had a reaction to heparin that resulted in reduced platelets and associated blood clots. Who should not be treated with Argatroban?
Argatroban should not be given to individuals who have major bleeding.
Special Warnings Concerning Argatroban:
Increased risk of bleeding is the most common complication of Argatroban. If you have the following conditions, your risk of bleeding may be increased:
severe high blood pressure
recent lumbar puncture, or spinal anesthesia
recent major surgery (especially involving the brain, spinal cord, or eye)
medical conditions that increase the tendency to bleed
stomach ulcers
What should I tell my doctor or healthcare provider?
Because certain other medications can interact with Argatroban, and may increase the risk of bleeding, review all medications that you are taking with your healthcare provider, including those that you take without a proscription.
Tell your doctor if you are taking blood thinners.
What are some possible side effects of Argatroban? (This is not a complete list of side effects reported with Argatroban. Your healthcare provider can discuss with you a more complete list of side effects.)
Bleeding is the most common side effect.
Other side effects may include:
shortness of breath
low blood pressure
fever
diarrhea
For more detailed information about Argatroban, ask your healthcare provider.
Link to Argatrobans Approved Labeling
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AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:18 AM
#13
Argatroban is also used in patients undergoing certain heart procedures such as percutaneous coronary interventions (PCI) or cardiac cathetherization as in this case who are at risk or have had a reaction to heparin that resulted in reduced platelets and associated blood clots. ___________________ seeking study partner in USMLE, Canadian MCC OSCE examination
AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/18/06 - 12:20 AM
#14
Argatroban is the ONLY direct thrombin inhibitor indicated for both prophylaxis and treatment of thrombosis in patients with heparin-induced thrombocytopenia (HIT).
A thrombin inhibitor !!! ___________________ seeking study partner in USMLE, Canadian MCC OSCE examination
MAZI Forum Elite
Topics: 8 Posts: 245
06/18/06 - 08:05 AM
#15
good question and explanation thank you
achilles Forum Guru
Topics: 90 Posts: 1,228
06/19/06 - 06:11 AM
#16
well i do realise that the thrombocytopenia could be because of heparin ( the famour HIT) but the question right now asks for the reason for absent brachial pulse and not the reason for thrombocytopenia. ___________________ " it's not whether you get knocked down, it's whether you get up" " i have miles to go before i sleep "
achilles Forum Guru
Topics: 90 Posts: 1,228
06/19/06 - 06:11 AM
#17
why would HIT cause absent brachial pulse ? ___________________ " it's not whether you get knocked down, it's whether you get up" " i have miles to go before i sleep "
an Forum Guru
Topics: 19 Posts: 437
06/19/06 - 06:44 AM
#18
beacuse the antibodies to platelet factor 4 cause 2 things..destruction of platelets(thrombocytopenia) and activation of platelets(resulting in thrombosis)...hence HIT 2 is also called HITT(heparin-induced thrombocytopenia thrombosis)..and the thrombosis explains the absent brachial pulse. ___________________ I don't believe in miracles...I rely on them. And sometimes, I create my own.
achilles Forum Guru
Topics: 90 Posts: 1,228
06/19/06 - 06:46 AM
#19
wonderful ! thanks an, i did'nt know that. ___________________ " it's not whether you get knocked down, it's whether you get up" " i have miles to go before i sleep "
AAAAA Forum Fanatic
Topics: 156 Posts: 1,991
06/19/06 - 09:54 AM
#20
HIT causes thrombocytopenia and thrombosis and it is arterial thrombosis that causes the brachial artery to have no blood flow and becomes pulseless. ___________________ seeking study partner in USMLE, Canadian MCC OSCE examination
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