Comments on: Damned if You Do….

By: Debbie

Debbie — Thu, 12 Jan 2012 02:28:48 +0000

And what is our definition of elderly? Does a little old 85-year old lady need her Coumadin considering the risk for stroke? She is at high risk for falls, which of course we see in the ER, pelvic fracture, retroperitoneal bleed, etc……

By: anon

anon — Mon, 02 Jan 2012 18:17:51 +0000

In my experience working in clerical in my early 20′s in a Primecare office patients are far and above more likely to respond to a bleeding event than any other potential problems. We had several strokes come in days after onset of symptoms, one I was able to ‘diagnose’ over the phone (went to the ER but our Doc still cares for pt inpatient). Too many pt appt request calls ended up with a phone call to 911 while I verified the patients location address. Injuries from pt’s on Coumadin? ‘Hi I fell off a ladder changing a lightbulb and have a bruise on my back, I need to see the Dr.” Bing! We have a Coumadin pt- off to the triage nurse, either an appt was booked, or if it was severe pt was sent to ER for evaluation.

By: RSDS

RSDS — Sun, 01 Jan 2012 21:54:31 +0000

If you put someone on Coumadin, and years later when surgery is needed to remove Squamous cell skin cancer, so that person is taken off of the Coumadin, with the result that they have a stroke the day before the stitches are to be removed, before they could be restarted on Coumadin.

The cancer surgery was a success. Dad was expecting, and planning on, living for at least ten years longer. Instead, Monday afternoon, the day before his stitches were to be removed he had a stroke.

He was taken the two blocks (less than 300 feet) to the county district hospital by ambulance. At the ER, after a brief glance by the FP Dr. on duty (this hospital does not have any ER doctors), his gurney was stashed in the corner of a storage room, while waiting for the passing of the window of time, when a “clot-buster” med could have been used. While still in the storage room, a foley catheter was inserted. Then Dad got a CT scan and was admitted to a room.

He received some fluids IV, but not enough to keep the urine that I could see in his bag from being very dark. He could not swallow, so he could not eat (he was very underweight to start with). He could not be tube fed, because ALL of the available foods were gluten based, and he was gluten-intolerant.

Thursday Dad never woke up.

Best to avoid using any rat poison on humans.

By: ERP

ERP — Sat, 31 Dec 2011 15:35:27 +0000

Yes, I know the indications but the problem comes when it is absolutely indicated from a cardiac point if view. The other stuff like h/o bleeding, falls, etc just throw a monkey wrench in.

By: CardioNP

CardioNP — Fri, 30 Dec 2011 21:46:03 +0000

Our motto in cardiology: We can give you back blood, we can’t give you back brain.
Short of an absolute contraindication, they should be anticoagulated based on CHADS2 – if you use the more recent Vasc modification, then the indication for anticoagulation is stronger.

But I understand your predicament. I’ve had to order more than my share of head CTs for c/o HA, trauma and found several bleeds.

Pradaxa is a bit scary since there is no reversal agent and an increased risk of GIB c/w coumadin.

By: Bill

Bill — Fri, 30 Dec 2011 20:05:17 +0000

From what I’ve read about Pradaxa, there doesn’t seem to be enough information just yet. Renal dosing is a little weird (75mg if CrCl < 30, but they've never done a study to back that up), doesn't seem to be a standardized antidote for overdose like with warfarin. I believe there's already been deaths reported as a result of Pradaxa-related bleeding events. Though the data isn't there, I'm interested to see how Pradaxa's place in therapy changes over the next few years. It seems to me that the best option is to always be up front and honest with your patient, explain the risks and benefits, and let them have a role in making an informed decision that they're comfortable with.

By: Dr. Grumpy

Dr. Grumpy — Fri, 30 Dec 2011 16:41:28 +0000

Pradaxa!