POTD: Emergency reversal of antiplatelet agents in intracerebral hemorrhage?

Clinical Scenario:  78 yo M with hx of CAD and DM, presents with right sided weakness that started one hour prior to arrival, denies trauma.  He is found to have an intracerebral hemorrhage on CT.  As you go through his medication list, you notice that he is on antiplatelets.  His home health aid at bedside says he takes all his medications daily and at baseline, he ambulates without assistance and feeds himself.  

Question: Do you reverse the antiplatelet agent?

A 2010 clinical review in World of Neurosurgery by Campbell et al says “at present, the literature contains insufficient information to establish any guidelines or treatment recommendations.  In light of this, the current authors have proposed a protocol for antiplatelet reversal in both spontaneous and traumatic acute ICH.”

That same year, Scott Weingart had a podcast with sample reversal guidelines in patients on antiplatelets with traumatic head bleeds, which included DDAVP and 1 donor pack platelets.

In 2013, Martin and Conlon had a Best Available Evidence article in Annals of Emergency Medicine which concluded that “there are no compelling data currently supporting the use of platelet transfusion in the management of patients with spontaneous or traumatic intracerebral hemorrhage who are receiving antiplatelet medications.  It would be within the standard of care to withhold platelet transfusion in patients with either spontaneous or traumatic intracerebral hemorrhage who are receiving antiplatelet therapy.”

In 2016, the PATCH trial by Baharoglu et al was published.  It was a randomized multicenter trial where 190 patients who were on antiplatelet therapy with nontraumatic intracerebral hemorrhage were either placed in standard care or standard care with platelet transfusion groups.  The authors’ conclusion was that “platelet transfusion seems inferior to standard care for people taking antiplatelet therapy before intracerebral hemorrhage.  Platelet transfusion cannot be recommended for this indication in clinical practice.”

Take home point:  It is within standard of care to withhold platelets from these patients and a recent randomized trial showed potential harm with platelet transfusion in atraumatic intracerebral hemorrhage.

Want to read more?

http://www.annemergmed.com/article/S0196-0644(12)00295-8/abstract

https://emcrit.org/racc/reversal-head-bleeds/

http://www.emdocs.net/platelets-ddavp-management-intracranial-hemorrhage/

http://rebelem.com/patch-trial-hold-platelets-spontaneous-intracerebral-hemorrhage/

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30392-0/abstract

http://thesgem.com/2017/06/sgem182-platelet-transfusions-for-intracerebral-hemorrhage-patch-dont-do-it/

http://www.worldneurosurgery.org/article/S1878-8750(10)00232-9/fulltext

POTD: Post-intubation Complications

Clinical Scenario:  You just walked away from an uneventful intubation to chart when your nurse tells you the patient is now hypoxic to the 70s.  

Question 1: What are some things you're considering as you walk back into the patient's room?

DOPES!

D – displacement of ETT

O – obstruction of ETT

P – pneumothorax

E – equipment problem

S – stacked breaths

Question 2: What if the nurse told you that the patient became hypotensive (instead of hypoxic) when his BP was normotensive prior to the intubation?

AH SHITE!

A – acidosis / anaphylaxis

H – heart (tamponade, pulmonary hypertension)

S – stacked breaths

H – hypovolemia

I – induction agent

T – tension pneumothorax

E – electrolyte

Want to read more?

https://emcrit.org/racc/finger-thoracostomy/

https://emcrit.org/racc/origins-of-the-dope-mnemonic/

https://lifeinthefastlane.com/ccc/post-intubation-hypoxia/

http://rebelem.com/post-intubation-hypotension-the-ah-shite-mnemonic/

https://umem.org/educational_pearls/485/

POTD: Trauma Tuesday! RhIG in the Pregnant Trauma Patient

Clinical Scenario:  26 yo F G1P0 at 33 weeks pregnancy presents via ambulance after a MVC.  She was a seatbelted driver with airbags deployed, no intrusion into her compartment.  She’s complaining of abdominal pain.  On exam, she has a seatbelt sign and very mild vaginal bleeding.  While placing your orders, you wonder if there are any lab tests that you should order specifically in a pregnant trauma patient.  You also wonder if you should go ahead and order her RhIG while you’re on the computer…  

Question:  Who do you give RhIG to?  How much do you give?  How much time do you have from injury to give it?  What labs do you order?

Rho(D) immune globulin (RhIG, aka Rhogam) is given to Rh negative females for concerns of isoimmunization during fetomaternal hemorrhage (there’s a break in placental barrier and fetal Rh positive blood enters maternal circulation).   As little as 0.01-0.03mL of fetal blood can cause isoimmunization.

A type and screen is needed initially to determine the Rh status of the patient.  A Rh negative female should receive an initial prophylactic RhIG dose of 300mcg IM within 72 hours of injury.  This dose protects against 30mL of fetal blood.  However, depending on the amount of fetomaternal hemorrhage, the patient may need more RhIG. To determine this, a Kleihauer Betke test should be ordered to quantify the degree of fetomaternal hemorrhage (A blood sample from the female is drawn and placed in an acid-elution assay and stained.  The fetal RBCs are left on the smear as rose pink while the maternal cells turn “ghost-like”).  The percent fetal cells is resulted and the additional number of vials of RhIG needed can be further calculated (check out this link for an example). The Kleihauer Betke test has a threshold of 5mL to be positive, so even if it is negative, it does not mean there was no fetomaternal hemorrhage.  **Do not underdose RhIG**

Want to read more?

https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/#sm.00019l0wujcacfjxrjy2901y3szy0

http://www.emdocs.net/trauma-management-of-the-3rd-trimester-pregnant-patient-pearls-pitfalls/

https://lifeinthefastlane.com/trauma-tribulation-006/

https://www.ncbi.nlm.nih.gov/books/NBK430876/

http://www.trauma.org/archive/resus/pregnancytrauma.html

https://www.uptodate.com/contents/prevention-of-rhesus-d-alloimmunization-in-pregnancy