POTD: New anticoagulant reversal recommendations

The American College of Gastroenterology and their corresponding Canadian group recently published a new guideline for the management of anticoagulants and antiplatelets during acute GI bleed.

Their recommendations in the setting of ACUTE GI BLEED are as follows:

·      For patients on warfarin, they suggest AGAINST giving FFP or Vitamin K; if needed, they suggest PCC compared with FFP. Their review of the data suggests PCC resulted in a quicker resolution of supratherapeutic INR, but no direct comparison of mortality or hemostasis, against FFP or even placebo. 

·      For patients on DOACs (Apixaban (Eliuquis)  Dabigatran (Pradaxa), Rivoraxaban (Xarelto)), they suggest AGAINST PCC administration; they suggest AGAINST direct reversal with idarucizumab in the case of Pradaxa, or andexanet alfa in the case of Eliquis or Xarelto. (Their is a paucity of data regarding their use and thrombotic potential. There appears to be a trend towards improvement of hemostasis, and they do open the door for conditional use in life threatening GI bleed where the DOAC has been taken within 24 hours. 

·      They suggest AGAINST platelet transfusions for those on platelet inhibitors. (data suggests harm and increased thrombotic events)  

·      For patients on ASA, they suggest AGAINST holding it; if it has been held, they suggest resumption on the day hemostasis has been endoscopically confirmed.

NOTABLY,  all of these recommendations are CONDITIONAL, with LOW TO VERY LOW CERTAINTIES of EVIDENCE.

The guidelines were developed by a working group from the ACG and GAC, including gastroenterologists, cardiologists, and hematologists, who attempted to make an evidenced based approach to these clinical questions, reviewing relevant literature and RCTs.

As an overall summation of the data, there is poor evidence that in ACUTE GI bleed, administration of reversal agents resulted in less bleeding, and have a risk of thromboembolic events. The cited RCTs are mostly with very small n-values (most less than 200), are often manufacturer funded, and mortality and outcomes based data is incredibly limited.  

This is obviously a very gross overview. A more detailed discussion can be found in their paper below: 

https://pubmed.ncbi.nlm.nih.gov/35368325/

POTD: Drowning

POTD: DROWNING

Causes:

·     misadventure

·     inadequate supervision of small children

·     neurological event e.g. epilepsy, stroke

·     cardiac event e,g, MI, HCM, dysrhythmia, long QT, short QT

·     impaired judgement e.g. intoxication

·     trauma

·     overdose

·     foul play

Pathophysiology:

·      Water enters the mouth

·      Voluntarily spat out or swallowed

·      One hold’s their breath until inspiratory drive is too high.

·      Water is aspirated in the lungs, and coughing occurs as a reflex

·      Continued aspiration leads to hypoxemia, loss of consciousness and apnea

·      Death usually occurs from seconds to a few minutes

Long term sequela are determined by:

Surfactant dysfunction and washout

Osmotic gradient damaging alveolar capillary membrane

Massive bloodstained pulmonary edema

Decrease in lung compliance, VQ mismatch atelectasis and bronchospasm

There is no significant difference in sea water vs fresh water, although fresh water has greater antibiotic prevalence.

HOSPITAL MANAGEMENT:

The Heimlich or other expiratory maneuvers are not believed to be of use in these patients.

Rewarm to 34C as quickly as possible; remove wet clothes, insulate with blankets, forced air warmer, warmed IVF, warmed lavage bladder, peritoneal, and chest lavage.

Early invasive ventilation as indicated by respiratory distress.

RESPIRATORY SUPPORT: ARDS lung protective ventilation, bronchodilation, consider proning and possibly ECMO.

KEY POINTS:

·      consider ECMO to aid in both respiratory and hypothermic management.

·      Resuscitation focus should be on ventilation due to loss of surfactant.

·      Hypothermia can be neuroprotective: hours of resuscitation may still lead to complete recovery.

·      Antibiotics should only be given if water was grossly contaminated, glucocorticoids are not recommended, and there is no strong data on the use of surfactant.

·      Symptomatic patients, those with shortness of breath, chest pain, cough, nausea or vomiting, should be monitored in the ED for a minimum for 6 hours and should be counseled on prevention and risk factors for drowning.

REFERENCES:

https://litfl.com/drowning/

https://www.aliem.com/resuscitation-of-a-drowning-victim/

EMS Protocol of the Week - Amputation (Adult and Pediatric)

Unfortunately, we’re not yet at the point of prehospital limb reimplantations, so until then, the protocol for amputations is pretty sparse – sterile wet-to-dry dressing, indirect cold storage, don’t let anything freeze, and transport.

That’s it!

Short email this week, don’t you think that deserves…a hand?

www.nycremsco.org for plenty of protocols, not enough jokes.

Dave