Coumadin toxicity

[harold1981]

This interesting case has been presented somewhere else on the internet, and is worth sharing with you guys:
A patient is brought in by EMS with an ´´allergic reaction with a swollen purple tongue and bruising of the chin and neck´´.
The ED physician identifies the situation as coumadin toxicity with hemorrhage of the tongue. Bloodwork reveals an INR >100 at that time. The patient is immediately intubated with direct laryngoscopy under ketamine, right before his airway collapses (within 45 minutes after onset), and treated with vitamin K and K-Centra and admitted to the ICU.

It brings me to three questions:
- Would tranexemic acid be of any help in this particular case in the pre-hospital phase? I know that vitamin K and TXA act on completely different mechanisms of the coagulation cascade, but still: would TXA do any good?
- Why would the tongue bleed first with such a high INR and not the brain or the intestines?
- Has any of you seen a case like this in your career? (not angiodema secondary to ACE-inhibitors or anaphylaxis, which is a completely different animal)

 

[E tank]

TXA and aminocaproic acid are useful when there is tissue destruction which releases clot dissolving enzymes. Unless there was super imposed trauma in this case, it wouldn't add anything to the treatment.

There is no telling where else a patient like this would bleed. Maybe he just bit his tongue.

Never seen an INR that high from Coumadin. What is meant by intubated right before airway collapse? The tongue suddenly became massive?

 

[Carlos Danger]

INR over 100?

I can't think of any reason why the tongue would bleed, unless it was traumatized in some way. The most common place for spontaneous bleeds is the brain.

 

[GMCmedic]

Ive never seen it in person but I am aware of it. I cant readily remember why the tongue bleeds

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[zzyzx]

I would have to doubt that the INR was that high.
It is not unheard of to see "super therapeutic" INR levels in patients taking Coumadin. It is notorious for interacting with many other drugs.

 

[jbiedebach]

We had a lady come into the ER with an INR over 6 and she was bleeding from her eyes. Her tongue was normal and her airway was not affected. Treated with Vit K and admitted. Only time I have seen it.


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[Ewok Jerky]

I've never heard of an INR anywhere near 100. Highest I have ever seen is 13. Once you are up past 9 or 10 you can really bleed from anywhere including the tongue, Not just your guts.