I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.
You can find more things on the FRCEM on this site here
(featured image, Gonegonegone on Wikipedia, CC license)
This is a key topic and the key guidelines (I think) are listed here
- 2011 BSH Warfarin
- 2014 BSH non warfarin anticoagulants and effects on testing
- 2012 BSH management of bleeding on anti thrombotics
Outline the agents and their mechanisms?
- Warfarin
- vitamin K anatgonist
- inhibits 2, 7, 9 and 10
- Dabigatran
- direct thrombin inhibitor
- the ‘Xabans’
- 10a inhibitor (oral enoxapain…)
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How should we manage bleeding on warfarin?
- major bleeding
- 25-50 units/kg of PCC
- vitamin K 5mg
- FFP only if PCC not available
- non-major bleeding
- vit k 1-3mg
- INR>5 no bleeding
- withhold
- INR>8 no bleeding
- withhold
- 1-5mg vit K orally
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How should we manage bleeding on dabigatran?
note the BSH guidance is a few years old so no mention of Idarucizumab. NICE has an evidence summary on it
- cessation
- general haemostasis
- if within 2 hrs consider charcoal
- they mention dialysis
- in life threatening bleeding they mention the kitchen sink approach
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How should we manage a xaban?
- please see above and cross fingers…
- kitchen sink an option
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How should we manage major bleeding with lytics?
- “within 48 hrs’
- FFP 12ml/kg
- TXA
- if fibrinogen low then give some
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How should we monitor the new guys?
- in general you don’t
- ecarin clotting time suggested for dabigatran
- most probably affect APTT/PT but these are actually assay specific so check local gudiance
- the APTT is a crude measure of activity of dabigatran
- the PT is probably a better measure of rivaroxaban
- guidance is clear that patients can have totally normal PT/APTT with significant anti coagulation with the new agents
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