sweetybokhari
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An 80-year old man who is taking warfarin because of history of atrial fibrillation,is found on routine blood work to have INR of 7.2.which of the following is the best immediate management of this problem?
1) hold the warfarin for 3 days
2) vitamin k 1 mg orally
3)vitamin k 10 mg intravenously
4) fresh frozen plasma intravenously
5) desmopressin(DDAVP)
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| new_n_lost
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2) vitamin k 1 mg orally ??
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| sprint123
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2 looks reasonable
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| AAAAA
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A 43-year-old man is evaluated for palpitations. He has no prior personal or family history of cardiovascular disease, diabetes mellitus, or hypertension. His cardiovascular examination is unremarkable with the exception of an irregular rapid heart rate. Lung examination is normal.
Laboratory testing, including thyroid function, is normal. The chest radiograph is normal. The electrocardiogram is shown (Figure 25). Based on his report and symptoms, it is suspected that the patient has been in this rhythm for approximately 5 hours. The patient converts to sinus rhythm spontaneously while in the emergency department, and the subsequent electrocardiogram is normal.
What is the most appropriate management plan for this patient?
A Outpatient anticoagulation
B Inpatient anticoagulation with heparin
C Transesophageal echocardiogram
D Aspirin
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| NE
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The should be A
*If the INR is above the therapeutic zone but below 5 and if the patient has no haemorrhagic manifestation or does not require rapid correction of coagulation before surgery:
suppress the next dose of AVK, and recommend the treatment with a lower dose as soon as the desired INR isobtained.
*If the INR is very close to the desired INR, reduce the daily dose directly without suppressing a dose. -
*If the INR is over 5 but below 9 and the patient has only minor haemorrhagic manifestations: - In the absence of a haemorrhagic risk factor, suppress one or two doses of AVK, measure the INR more frequently and recommence the AVK at a lower dose as soon as the desired INR is obtained; - When the patient presents other haemorrhagic risks, suppress one dose and give vitaminK: either 1 to 2.5 mg orally or 0.5 to 1 mg in slow perfusion over one hour.
* If the INR is over 9, in the absence of bleeding, suppress one dose and give vitamin K: either 3 to 5mg orally or 1 to 1.5 mg in slow perfusion over one hour, which will enable a reduction of the INR in24 to 48 hours, then recommence the AVK at a lower dose. Monitor the INR and repeat thetreatment by vitamin K if necessary.
- If a rapid correction of the anticoagulant effect is necessary in the event of serious haemorrhagic manifestation or a major overdose of AVK (eg INR >20), give an intravenous dose of 10 mg of vitamin K slowly, associated (depending on the urgency) with FFP or concentrated prothrombincomplex (20 to 40 UI.kg-1of Factor IX depending on the initial INR value) which will enable a veryrapid correction of the haemostatic anomaly.
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| sweetybokhari
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thanks NE, very good explanation,you make concept very clear.
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| docnikki
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WONDERFUL!
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| new_n_lost
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I choose Vit K Oral due to this Reason.
I Found this Explanation in the :- http://www.emedicine.com/emerg/topic872.htm
- Chronic intoxication resulting from therapeutic use of warfarin can be evaluated with a careful physical examination and a measurement of the PT and INR.
- If INR is higher than therapeutic levels but less than 6 and the patient is not bleeding, withhold warfarin for 2-3 days and restart when the INR approaches the therapeutic range.
- If INR is higher than 6 but less than 10 and the patient is not bleeding, or less than 6 but the patient requires more rapid reversal for elective surgery, administer 10 mg of oral vitamin K-1 with the expectation that the INR begins falling within 8 hours and is close to the therapeutic range in about 24 hours.
- If the INR is higher than 10 and the patient is not bleeding, a higher daily dose of oral vitamin K-1 may be administered. In the setting of superwarfarin-induced coagulopathies, 50-200 mg is recommended.
- If very rapid reversal of anticoagulant effect is essential because of serious bleeding or the INR is very high (eg, >20), administer fresh frozen plasma or prothrombin complex concentrate in addition to oral vitamin K-1.
- If the patient has a critical need for ongoing anticoagulation (eg, mechanical heart valve), heparin can be given as a temporary measure while fully reversing the effects of warfarin.
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| new_n_lost
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Packed red cells and fresh frozen plasma may be required for immediate management of life-threatening hemorrhagic complications. Vitamin K is the only effective antidote for long-term management, but reversal of anticoagulation takes several hours. Administering vitamin K IV has no advantage, and reports have documented acute cardiovascular collapse after administration by this route, presumably caused by an anaphylactoid reaction. IM or SC administration may cause hematoma.
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| AAAAA
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new_n_lost wrote:I choose Vit K Oral due to this Reason. I Found this Explanation in the :- http://www.emedicine.com/emerg/topic872.htm - Chronic intoxication resulting from therapeutic use of warfarin can be evaluated with a careful physical examination and a measurement of the PT and INR.
- If INR is higher than therapeutic levels but less than 6 and the patient is not bleeding, withhold warfarin for 2-3 days and restart when the INR approaches the therapeutic range.
- If INR is higher than 6 but less than 10 and the patient is not bleeding, or less than 6 but the patient requires more rapid reversal for elective surgery, administer 10 mg of oral vitamin K-1 with the expectation that the INR begins falling within 8 hours and is close to the therapeutic range in about 24 hours.
- If the INR is higher than 10 and the patient is not bleeding, a higher daily dose of oral vitamin K-1 may be administered. In the setting of superwarfarin-induced coagulopathies, 50-200 mg is recommended.
- If very rapid reversal of anticoagulant effect is essential because of serious bleeding or the INR is very high (eg, >20), administer fresh frozen plasma or prothrombin complex concentrate in addition to oral vitamin K-1.
- If the patient has a critical need for ongoing anticoagulation (eg, mechanical heart valve), heparin can be given as a temporary measure while fully reversing the effects of warfarin.
I choose to give vitamin K because I use risk stratificaton.
1. The risk of this patient potentially develops bleeding is high because of his age
2. If this is a younger patient, around 60, I will just hold off coumadin
3. INR 7.5 m on coumaudin, you do not know if the INR is going further up or going down, so on the safe side clinically (in my real practice as well as exam to prevent an elderly patient at age 80 to have a hemmorhhagic stroke and introcerebral bleeding, I will give Vitamin K PO because they only give one reading of INR, if you hold the counmadin, and the next day, the counmadin is 10 and start having a hemmorrhagic stroke and intracerebral bleeding, it is bad
eMedicine is good but must base on this particular clinical question, so giving vitamin K is reasonable
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| AAAAA
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INR may still be on the way up so a 80 year old man with 7.5 INR in real life and exam should be given vitamin K on the safe side
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| new_n_lost
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Thanks for the Explanation along With UR experience, Truly Appreciate it
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"never argue with a fool, they'll bring you down to their level and beat you with experience" FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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| new_n_lost
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Cos its different on how u react in Real situation n a textbook sceanrio its good to know the Clinical Decision making with a Hindsight.
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"never argue with a fool, they'll bring you down to their level and beat you with experience" FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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| AAAAA
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Thank you !
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| docnikki
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sweetybokhari whats the answer to this quest that u put..if u have the answer post taht also plz and if you dont plz tell us whether it was NBME quest thanks.
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| sweetybokhari
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sorry docnikki i donot have answer of this question.it is candian self assessement exam question,they charge 40 dollers for this exam but donot provide the answers.still i am confused about answer between 1 and 2 options.any comment appreciated.thanks
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| sweetybokhari
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in above question i posted you guys choose answer vitamin k 1mg orally,in this question what will be your answer?
An 80-year old man,who is taking warfarin because of history of atrial fibrillation,presents to the emergency room with syncopal episode.His stool has been black.his hemoglobin is 65g/L and INR 7.2.which one of the following is the best immediate approach to the management of the raised INR?
1) vitamin k, 1mg orally
2)vitamink,10 mg intravenously
3)hold warfarin for 3 days
4)desmopressin(DDAVP)
5) 4 units of fresh frozen plasma
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| new_n_lost
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1) vitamin k, 1mg orally
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"never argue with a fool, they'll bring you down to their level and beat you with experience" FORUM RULES-- Those who believe in telekinesis, raise my hand. I get enough exercise just by pushing my luck --P4U World.." The pure and simple truth is rarely pure and never simple."
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| docnikki
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for the first quest though practically 2) is the answer but according to the guidelines it's 1)
For the first quest I also feel that most imp action is to hold back warfarin and then INR can be measures and if its increasing or not falling back then we can give Vit K 1mg orally
For the second quest since he is bleeding and also aged person then he straight away needs Fresh frozen plasma.
If you dont agree plz give your explaination too.
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