1. Anticoagulation Reversal May 11, 2013

2. Objectives Develop an approach for treating patients with iatrogenic coagulopathy Understand recent changes in STEMI care Review the ICH treatment protocol

3. Patient Care Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice ACGME Competencies Addressed

5. Tissue factor pathway Contact activation pathway

6. Tissue factor pathway Contact activation pathway Haemophilia A Haemophilia B

7. What is the mechanism of action of warfarin?

8. What is the mechanism of action of warfarin? Inhibits Vitamin K epoxide reductase

9. The American College of Chest Physicians guideline for the reversal of anticoagulation therapy (8th ed.).

10. Vitamin K epoxide reductase

11. What clotting factors are affected by warfarin?

13. 78 year old with history of PE presents with weakness and UTI. INR = 8.

15. 58 year old with history of atrial fibrillation and HTN on warfarin presents with ICH. GCS = 6 and INR = 4.

17. 67 year old with pmh atrial fibrillation on warfarin presents with brisk nose bleed. INR = 6.

18. What is the universal donor FFP type?

19. AB

20. One unit plasma replaced what percent of clotting factors?

21. 2.5%

22. How low can you get the INR with FFP?

23. 1.5

24. Name two problems with FFP

25. Time Volume

26. PCC What types of PCC are there?

27. 3 factor 4 factor

28. 3 Factor PCC Profilnine II IX X Very small amount of VII

31. Kcentra 4F-PCC – II – VII – IX – X

34. What is the mechanism of action of Xabans?

35. Xa inhibitor

36. Xabans -rivaroxaban (Xarelto)

37. How would you treat major bleeding in someone on Rivaroxaban?

38. PCC (?)

39. Xabans Rivaroxaban (Xarelto) Xa inhibitors PCC

40. Dabigatran (Pradaxa) What is mechanism of action?

41. dabigatran (Pradaxa)

42. Dabigatran (Pradaxa) Renal metabolism Can not be monitored Normal PTT helpful, but abnormal PTT not helpful PCC? FEIBA (Factor eight inhibitor bypass activity)?

43. What is the mechanism of action of heparin?

44. Heparin Activates Antithrombin III

45. Heparin Activates Antithrombin III

46. You have a patient in the ED with a non-STEMI. You put them on heparin. They develop a severe headache and you diagnose an ICH. What do you do?

47. How do you treat a patient with major bleeding on heparin? Protamine

48. LMW Heparin

49. Low Molecular Weight Heparin Blocks Xa Protamine causes partial reversal

50. Tissue Plasminogen Activator Cryoprecipitate Platelets FFP Heparin reversal if on heparin

51. Tissue Plasminogen Activator

53. Safest central line site for a patient with an elevated INR

54. Internal Jugular

55. What should the INR be before dong an LP?

56.  1.5

57. ICH Protocol

58. Antiplatelet Therapy Cyclooxygenase Inhibitors P2Y12 receptor antagonists (ADP) GP Iib/IIIa antagonists

61. How does aspirin work?

62. Irreversible inhibition of COX-1 (cyclooxygenase 1) Blocks TXA2 production (thromboxane A2)?

65. Treatment of major bleeding for a patient on aspirin?

66. Platelet transfusion DDAVP (analog of vasopressin)

67. 1 unit of single donor (pheresis) platelets = how many units of pooled donors?

68. 1 unit of single donor (pheresis) platelets = how many units of pooled donors? 6-10

69. What is Aggrenox?

70. Aspirin Dipyridamole

72. What is the half life of clopidogrel?

73. 6-7 hours Binds P2Y12 receptor irreversibly

75. P2Y12 Inhibitors Clopidegrel (Plavix) Prasugrel Ticagrelor

76. What are two drug classes you may want to avoid for patients on clopidogrel?

77. PPIs Macrolides

78. Which P2Y12 inhibitor should you avoid in a patient with a history of TIA or CVA Prasugrel

80. How do you treat a patient on clopidogrel with major bleeding?

81. Platelets – 2 units DDAVP? fFVII?

82. GPIIbIIIa Inhibitor Abciximab (ReoPro) Triofiban (Aggrastat) Eptifibatide (Integrillin)

84. STEMI Protocol

85. What antiplatelet is given to STEMI patients at SJH and MMC?

86. Ticagrelor (Brilinta)

87. Ticagrelor "David Griffen" wrote: Frank, Could you please refresh my memory - what was the rationale regarding replacing Plavix with ticagrelor for the STEMI orders? It's proven clinical superiority in head-to-head ACS clinical trial (PLATO) for which it has received a Class I recommendation in the 2013 ACC/AHA STEMI guidelines and is preferred over plavix in the 2012 European STEMI guidelines.

88. What has just replaced heparin in the STEMI (Star 80) at MMC?

89. Angiomax (bivalirudin) Revisable inhibitor of thrombin it is a synthetic congener of the naturally occurring drug hirudin (found in the saliva of the medicinal leech Hirudo medicinalis

90. Anticoagulant Therapy to Support Primary PCI For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended: UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered; or Bivalirudin with or without prior treatment with UFH. I IIaIIbIII I IIaIIbIII

91. Anticoagulant Therapy to Support Primary PCI In patients with STEMI undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist. Fondaparinux should not be used as the sole anticoagulant to support primary PCI because of the risk of catheter thrombosis. I IIaIIbIII I IIaIIbIII Harm

92. Why I get confused Aggrenox Angiomax Aggrastat

93. Objectives Learn strategies for treating patients with iatrogenic coagulopathy Understand recent changes in STEMI care Review the ICH treatment protocol

94. Dr. J. Wall on coagulopathy in trauma June 6 th.

95. Recommended preparation CAEP 2012 Annual Conference June 3- June 6, 2012 – What's New in the Management of the Massively Bleeding Trauma Patient Dr. Sandro Rizoli