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
Following is a comment I received about one reader’s experience with this drug. Why don’t we just set some hard parameters or age limits on the use of such drugs? I’ll provide the opposing view tomorrow.
“So far, one clinical trauma experience- 70+ yo male cut his fingers working with a model airplane engine; on dabigatran. Blood loss nearly 1 L., no control of bleeding w. 2 hours of tourniquet time. Required microvascular ligation of digital vessels. Impressively powerful anticoagulant.
You have to be aware of dosing times to know how long anti-coag effect is likely to endure. Lab tests of little help. No demonstrated efficiacy of Factor VIIa or PCC; in fact, PCC has been shown not to help in one trial. It is effective with Xarelto, though.
Our blood bank stays up at night worrying about this drug, with good reason, since we do our own collections.
Clinicians prescribing this drug should look at bleeding risk scoring systems (HEMORR2HAGE, HAS-BLED) as well as the CHADS2 score before deciding to use this drug.
I suspect it will be ultimately replaced by the Factor Xa inhibitors.
N.B- New Zealand has been reporting a myriad of bleeding issues with this drug. Since it is a relatively closed system, their experience should be a bellweather.”
Trauma Program Director
Click here to download a reference sheet for dabigatran reversal.
Finally, a consensus report has been finalized by the Institute for Clinical Systems Improvement (ICSI) regarding bleeding in patients taking dabigatran (Pradaxa). I’ve written about the special problems posed by patients who are injured while taking this drug and related ones. I’ve also provided some management algorithms for consideration while complete ones were crafted. Well, here they are.
A workgroup of experts from hospitals here in Minnesota were convened to consider and provide a framework for managing these patients. A document was released recently to help guide their care.
To summarize, patients who experience a severe bleed, say from trauma, should be managed with:
- Holding the medication
- Evaluating bleeding. In trauma, this will generally involve CT scan.
- Consider the need for surgery
- Give activated charcoal if the drug was taken within 2 hours
- Consider dialysis
- Transfuse blood if hemoglobin / hematocrit needs to be improved
- Infuse plasma after 4 units of red cells, and cryoprecipitate after 8 units packed cells / 4 units plasma if needed
- Consider prothrombin complex concentrate or activated Factor VII in extreme cases
Click here to download the official document from ICSI.
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
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.