A 63-year-old man comes to the hospital due to sudden onset chest pain and dyspnea. He has a history of glioblastoma multiforme, for which he has been undergoing radiation treatment. His temperature is 36.1 C (97 F), blood pressure is 110/80 mm Hg, pulse is 118/min, and respirations are 26/min. Pulse oximetry shows 90% on room air. A CT pulmonary angiogram demonstrates a left-sided pulmonary embolism. The patient is started on continuous unfractionated heparin infusion. Several hours later, the patient begins to experience severe headache and quickly becomes unconscious. A CT of the head reveals bleeding into the tumor. After stopping the heparin infusion, administration of which of the following is indicated for immediate anticoagulant reversal?

Question

A 63-year-old man comes to the hospital due to sudden onset chest pain and dyspnea.  He has a history of glioblastoma multiforme, for which he has been undergoing radiation treatment.  His temperature is 36.1 C (97 F), blood pressure is 110/80 mm Hg, pulse is 118/min, and respirations are 26/min.  Pulse oximetry shows 90% on room air.  A CT pulmonary angiogram demonstrates a left-sided pulmonary embolism.  The patient is started on continuous unfractionated heparin infusion.  Several hours later, the patient begins to experience severe headache and quickly becomes unconscious.  A CT of the head reveals bleeding into the tumor.  After stopping the heparin infusion, administration of which of the following is indicated for immediate anticoagulant reversal?

Quizplus · Accepted Answer

11ec160b_3bd8_5f65_9249_d70575f64bf6_MD0001_00 Unfractionated heparin (UFH) and low-molecular weight heparins (LMWHs) are commonly used anticoagulants in the hospital setting. Heparin increases the effect of the naturally occurring anticoagulant antithrombin III (ATIII). Activated partial thromboplastin time (aPTT) is measured to monitor the therapeutic effect of heparin. Bleeding and heparin-induced thrombocytopenia are serious complications of heparin therapy. Bleeding due to heparin toxicity is treated with protamine sulfate, a specific antagonist. Protamine sulfate is a peptide that binds to heparin, forming a complex that has no anticoagulant activity. Although protamine is often used in the management of LMWH toxicity, it does not completely reverse the anti-Xa activity of LMWH. Vitamin K is used for reversal of warfarin overdose but requires new synthesis of coagulation factors. As a result, its full effect takes time to manifest. For this reason, in the setting of acute life-threatening bleeding due to warfarin, fresh frozen plasma (FFP) (contains all blood proteins and clotting factors) should be given. However, FFP is not useful for heparin overdose as it contains ATIII, which can further potentiate the effects of heparin. Prothrombin complex concentrates (PCCs), which contain the vitamin K-dependent factors II, VII, IX, and X, can be used to treat bleeding due to warfarin (not heparin) overdose (Choices A, D, and F). (Choices B and E) Platelet function is not affected by warfarin therapy. Aminocaproic acid and tranexamic acid inhibit fibrinolysis by inhibiting plasminogen activation. Educational objective: Protamine sulfate binds to heparin, causing chemical inactivation. Vitamin K and fresh frozen plasma can be used to reverse warfarin effects.

A 63-Year-Old Man Comes to the Hospital Due to Sudden