So my scenario I present you with is a G.I. bleed with a patient on blood thinners. He has received his regular dose and has had 2 large episodes of hematochezia, one earlier in the morning and late morning, with reported a large amount of dark tary stool. The patients vitals are stable but the smell has filled the whole downstairs and there is obvious signs of incontinent from earlier. For our Trauma center criteria there is a box that has "Anticoagulants" as a consider trauma hospital and transport to appropriate facility. However there are doctors orders to take this patient to a further ER then the closest trauma center approx. 10-15 minutes further from the Trauma center. This same doctor from this facility always writes the same ER to go to no matter what the call. For instance I had a stoke code come from the same facility where the orders were to take the pt to the further ER instead of the closest Base hospital (we transported to the closest) and everything was peachy. I know for falls and trauma with blood thinners it is taken seriously in our county. The patho of the bleed seemed possible to be significant enough to warrant going to a trauma center where they have a better prepared surgical team and equipment, or so I think even though it might not be trauma related there is still bleeding with anticoagulants. There was the doctors orders that were taken lightly due to previous orders being wrong. In hindsight it would have been best to contact the MICN prior, with the intended ER drop off. Please let me know your thoughts on the appropriateness of diverting due to 1.)G.I. bleed w/anticoagulants going to a trauma center. and sorry for the long read. Thanks!
Blood thinners and non-traumatic bleeding
- Thread starter Gheed
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I think you're vastly over thinking this issue.
You mentioned his vitals are stable, what were they? The hospital is very unlikely to take this guy to the OR emergently (or for that matter at all) it's far more likely he'll get scoped.....tomorrow. The doc wrote the orders most likely to the facility he has admitting privileges at so he can follow the patient rather than get yet another provider involved.
As far as the stroke...what made you call it a code stroke?
You mentioned his vitals are stable, what were they? The hospital is very unlikely to take this guy to the OR emergently (or for that matter at all) it's far more likely he'll get scoped.....tomorrow. The doc wrote the orders most likely to the facility he has admitting privileges at so he can follow the patient rather than get yet another provider involved.
As far as the stroke...what made you call it a code stroke?
I was the driver so I don't recall the vitals exactly but I know they were not of concern. I don't know the usual procedure for a common GI bleed but I have heard a story of finding a pt dead from one on the toilet so I figured they can be bad enough at times and with thinners it might need sooner action then others. But for the stroke it was +left sided facial droop and slouching to the left, as well as aphasia and unable to follow commands effectively with onset < 4 hours.
Summit
Critical Crazy
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With the limited amount of detail (particularly, no labs), I concur with the above. Hemodynamically stable? Not-altered? Not an emergency yet! They'll get scoped first. If it is not an UGIB, then they probably won't even get an NGT.
VFlutter
Flight Nurse
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The term "blood thinners" is commonly used for various drugs. It is nice to know if it is an anticoagulant (Warfarin) or an antiplatelet (clopidogrel).
Were they only on Plavix or Aspirin as well?
Few GI bleeds are extreme enough to need a trauma center unless they are caused by ruptured varices. Mild GI bleeds caused by anticoag therapy can be handled at nearly any hospital. Protonix drip, labs, then a GI workup the next day. Maybe some blood products if it is that severe. Pretty straight forward
Most of the patients on my floor end up with GI bleeds at some point. Better than an MI or Stroke
Well just because a patient has a GI bleed or even in shock doesn't mean they need trauma center services. Like was mentioned above, rarely do these patients go to surgery. If any urgent intervention is going to be done then it will probably be some sort of scope by a GI doc. So as long as the hospital has GI and surgery coverage then they should be able to handle these cases.
And it's important to know which medicines they are on because certain anti coagulants can be reversed while others can not.
And to clarify.... there are no "blood thinners". There are drugs that prevent platelet aggregation, referred to as anti-platelets, and there are those that inhibit certain steps in the coagulation pathway, referred to as anti-coagulants.
Plavix inhibits ADP and this inhibits platelet aggregation.
This impacts what we may potentially give a patient to try and reverse the medicine's effects. In the case of plavix I can check a specific lab test to see how much the platelets are inhibited and potentially may give platelet transfusion. Though the evidence for it is not strong at all, level 3 I believe, it's routinely done for life threatening bleeding.
If he was on Coumadin or some other anti-coagulant then I would need to check a different lab test and giving platelets would be useless.
If you really want to have a good understanding of what all goes into these decisions it goes back to knowing the physiology, pathophysiology, and pharmacology involved.... read about the mechanisms of actions of the common anti-platelets and anti-coagulants, about the coagulation pathway, about platelet activation, and about the lifespan of platelets and the different coagulation factors.
So, all that to say that telling me someone's on "blood thinners" doesn't help a whole lot.
And it's important to know which medicines they are on because certain anti coagulants can be reversed while others can not.
And to clarify.... there are no "blood thinners". There are drugs that prevent platelet aggregation, referred to as anti-platelets, and there are those that inhibit certain steps in the coagulation pathway, referred to as anti-coagulants.
Plavix inhibits ADP and this inhibits platelet aggregation.
This impacts what we may potentially give a patient to try and reverse the medicine's effects. In the case of plavix I can check a specific lab test to see how much the platelets are inhibited and potentially may give platelet transfusion. Though the evidence for it is not strong at all, level 3 I believe, it's routinely done for life threatening bleeding.
If he was on Coumadin or some other anti-coagulant then I would need to check a different lab test and giving platelets would be useless.
If you really want to have a good understanding of what all goes into these decisions it goes back to knowing the physiology, pathophysiology, and pharmacology involved.... read about the mechanisms of actions of the common anti-platelets and anti-coagulants, about the coagulation pathway, about platelet activation, and about the lifespan of platelets and the different coagulation factors.
So, all that to say that telling me someone's on "blood thinners" doesn't help a whole lot.
I understand shock doesn't make a patient a trauma candidate and that plavix is not technically called "blood thinner" I stated anticoagulant earlier because it is under "anticoagulants or antiplatelets" from trauma criteria. Blood thinner is a term use locally and bad habbit but it gets the point accross of what you are asking to many of the foreing nurses at the skilled nursing facilities we go to. Seems like from what people are saying here is unless a GI bleed is acute there is no need to go to a trauma center. I was looking for more of a BLS look at it but do appreciate all the info and help! Another question if you don't mind. Asa is specifically excluded from the list of antiplatelets, is this because it is a weak drug in that aspect?
mycrofft
Still crazy but elsewhere
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There are different types of "anticoagulants"
...and not all are actually "antocoagulants", but all are used to prevent thrombogenesis.
Plavix, ASA, coumadin, heparin, some meds I don't know about from outside the USA, and some new ones are hitting the market which advertise "no blood monitoring needed", but also caution about potential for GI bleeds including rectal. They all are different, they need different treatments (virtually none in the field) for OD's, drug mixture effects, and misadventures .
I personally know of one case where Pradaxa (not to be confused with Plavix) triggered a significant rectal bleed and took a month to resolve.
Use of NSAIDS with any of these, or alcohol, can have additive effects.
Any loss of blood, rectal or otherwise, is as significant as a loss of blood from any other site. Assess and treat, transport.
(My take on "blood thinner" is that it is kiddie-speak for the patients, not the professionals).
...and not all are actually "antocoagulants", but all are used to prevent thrombogenesis.
Plavix, ASA, coumadin, heparin, some meds I don't know about from outside the USA, and some new ones are hitting the market which advertise "no blood monitoring needed", but also caution about potential for GI bleeds including rectal. They all are different, they need different treatments (virtually none in the field) for OD's, drug mixture effects, and misadventures .
I personally know of one case where Pradaxa (not to be confused with Plavix) triggered a significant rectal bleed and took a month to resolve.
Use of NSAIDS with any of these, or alcohol, can have additive effects.
Any loss of blood, rectal or otherwise, is as significant as a loss of blood from any other site. Assess and treat, transport.
(My take on "blood thinner" is that it is kiddie-speak for the patients, not the professionals).
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The thing I worry about is the dosing that doesn't require testing and there's no antidote for it, when dealing with those meds.
Brandon O
Puzzled by facies
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Need for significant transfusion would be a legitimate reason for heading to a trauma center, whether or not the problem will be managed surgically. Most community hospitals won't have that volume of blood products on hand for immediate use. GI bleeds, at their worst (e.g. the ruptured varices), join major trauma as potential triggers for massive transfusion protocols.
EpiEMS
Forum Deputy Chief
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Related question: is vitamin K administered in the prehospital setting in any locations?
mycrofft
Still crazy but elsewhere
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THAT is one of the mysterious little jokes "Big Pharm" plays. Pradaxa level cannot be usefully checked, so they don't. and they advertise this inability as a positive thing! They could be checking actual clotting time (not PT or PTT), but what lab likes to watch paint dry...
mycrofft
Still crazy but elsewhere
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Googling "prehospital Vitamin K" elicited this URL:
http://www.ncbi.nlm.nih.gov/pubmed/19276776
Or, improvise:
Did you know the makers of V8 Juice do not test for Vit K content? Send them an Email or letter sometime.
EpiEMS
Forum Deputy Chief
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Yeah, I couldn't find much on the reversal of anticoagulants prehospitally. Is it not done for a similar reason that we don't find flumazenil in protocols?