1. To Clot Or Not To Clot… Emergency Care for Coagulation Disorders/Conditions Rebecca Goldsmith Pediatric Thrombosis/Hemophilia Nurse McMaster Children’s Hospital Current Concept in Pediatrics October 16 th, 2009

2. Objectives  Virchow’s Triad  Reasons for referrals  Line related DVTs  Anticoagulation of DVTs  Case study – keypad question  Clinic information  Questions

3. Virchow’s Triad Blood flow (stasis) Vessel Blood Wall Components

4. Reasons for Referrals  Prothrombotic workup  Deep Vein Thrombosis (DVT)  Pulmonary Embolism (PE)  Stroke  Fracture prophylaxis  Arterial thrombosis

5. Reasons for Anticoagulation  DVT  Cardiac prophylaxis(BT shunt, Fontan procedure, Norwood procedure)  Fracture prophylaxis  Arterial clot  Hereditary prothrombotic states  Stroke (pediatric pts. cerebral sinovenous thrombosis, CSVT) however, there is not a lot of evidence to support this

6. Line related DVTs  Clinical observation CVL dysfunction Limb or facial swelling distal to a CVL insertion site Superficial new collateral vein development Pain, swelling, or redness in limb Abdominal pain +/- fever without other explanation

7.  Confirmation of limb DVT can be made with - Compression Doppler U/S - Venogram - MRV

8. Treatment Options Tissue Plasminogen Activator has become the most commonly used thrombolytic agent in the pediatric population (TPA), in hospital. Converts endogenous plasminogen to plasmin the most useful assay is a fibrinogen level Low Molecular Weight Heparin (LMWH) LMWH has specific anti- factor Xa activity and reduced anti- factor IIa activity Xa therapeutic level is 0.5-1.0 U/ml in a sample taken 4-6 hrs post sc inj. Dosing of LMWH starts at 1mg/kg bid Warfarin is a Vitamin K antagonist and functions by reducing plasma concentration of vitamin K- dependent factors (II, VII, IX, X) Warfarin loading dose: 0.2mg/kg as a single night time dose. Dosage adjustments to be made until INR is 2.0-3.0

9. LMWH AdvantagesDisadvantage * Subcutaneous injections daily or twice daily minimal monitoring required reduced risk of interaction with other medication or diet reduced risk of heparin induced thrombocytopenia (HIT) probable reduced risk of osteoporosis in long-term

10. Warfarin Therapy Advantages Taken per os no injections Disadvantages *Therapeutic range of INR must be in place at least two consecutive days prior to removing LMWH * many drug interactions (ex. Antibiotics) * interacts with diet high in Vitamin K enriched foods *reduced bone density in pts taking warfarin for more than one year

11. Case Study Question- A 17 yr old female presents in ER.  She appears anxious, sweating.  She has a rapid HR and low BP.  c/o sharp chest pain and shortness of breath. She admits to taking oral contraceptive pills for three months.

12. You suspect which of the following? 1. Myocardial infarct 2. Pulmonary embolism 3. Pregnancy 4. Panic Attack

13. Pulmonary embolism  Confirm diagnosis with ventilation-perfusion scan

14. Clinic Information Pediatric Thrombosis Clinic Hamilton Health Sciences 1200 Main St West Hamilton 905-521-2100 ex 75970

15. References Monagle, P., Chan, A.K.C., deVeber, G, Massicotte, M.P. (2006).Pediatric Thromboemolism and Stroke (3 rd ed.). Hamilton, ON: B.C. Decker Inc. Resources: Machealth.ca Thrombosis Interest Group of Canada http://www.tigc.org/