11/10/2014 Antiplatelet and anticoagulation ICH

After an amazing resting weekend, I am back to learn more about stroke particularly hemorrhagic stroke. So lets keep going in our journey ... again, the best part of it is that we will be able to help people while walking our travel. 

1) When assessing ICH always keep in mind dysfunctional platelets in renal disease and intrinsic coagulopathy as in hemophilia and von Willebrand disease

2) ICH secondary to vitamin K inhibitor accounts for about 10-15% of ICH. With bleeds mostly multifocal including cerebellar vermis and hemorrhages into previously ischemic tissue.

3) The annual rate of ICH in pts tx with warfarin is 1%.

4) The main risk factors for warfarin associated ICH are HTN, age, intensity of anticoagulation, concomitant aspirin use, cerebral amyloid angiopathy, and leukoaraiosis.

5) Risk factors for hemorrhagic conversion of an ischemic stroke are: large infarct size, older age, hyperglycemia, sustained hypertension, thromboembolic mechanism, and preexisting micro hemorrhages on MRI.

6) Hemorrhagic conversion of an infarct

7) Warfarin and liver failure reversal: Vit K 10mg IV  in 10 min + PCC 50 u/kg IV. ( also aPCC, Kcentra) 

8) Unfractionated heparin reversal: protamine 1mg IV 

per 100u of heparin given in the first 30 min then 0.75mg per 100u for the next 30 min and 0.50mg per 100u of heparin given in the second hour. 

9) Low molecular heparin reversal: protamine 1mg IV per 1mg LMWH given in the last 8 hrs. 

10) Aspirin , NSAID or platelet aggregation inhibitors (clopidogrel/ticlopidine), uremic platelets, GP IIb/IIIa inhibitors reversal: DDAVP (desmopressin acetate) 0.3 ug/kg vi X 1 (20 ug in 50 ml NS over 15-30 min) and transfuse 5-6 units of platelets. 

Today we will do an extra one !!...

11) Thrombolytic induced coagulopathy reversal: 12 units of cryoprecipitate (to replace fibrinogen and factor VIII). 6-8 units of platelets.