Hey folks,
I’m lecturing at ACEP in Las Vegas this year. This is one of two lectures I’m giving there. If you are going to the conference and plan on coming to my lecture, don’t listen to this lecture; I’d rather you hear the real one in person.
But if you can’t make it this year, and you have 50 minutes, take a listen and let me know what you think.
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This Post was by Scott Weingart, MD.
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Hi, my name is Scott Weingart.
I am an ED
Intensivist from New York City. My career goal and the purpose of this blog and podcast is to bring Upstairs Care, Downstairs-–that is to bring ICU level care to the ED, so our patients can receive optimum treatment the moment they roll through the door.
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{ 8 comments… read them below or add one }
Great talk! Your site is an excellent resource!
Any suggestions for community hospitals that doesn’t have such ready access to unthawed plasma? Should we empirically give PCC (in Canada we have the 4-factor version)? Our goal is obviously to stabilize the patient (as much as possible) and send them to a trauma centre. If we are using PCC in this setting instead of waiting for the FFP to thaw, is there any literature on how much to use or when to repeat the dose (i.e. after how much units of blood)? Or is this all uncharted territory?
I appreciate your thoughts.
John
Yeah, evidence isn’t great, but I think after 4 units of blood, I would hit them with your PCC.
you can check out:
Critical Care 2009, 13:R191
Eur J of Cardio Surgery 2001;19:219
Eur J Anaes 2008;25:784
British Journal of Anaesthesia 102(3):345-354
Thanks!
This is a great lecture as usual.
I listened to this lecture back-to-back with your reversing coumadin in head bleeds talk, and although it may pertain more to your prior lecture, I’m curious to know what you do when you send an anticoagulated patient with minor head trauma home. Do you have them hold (or reverse) their coumadin given the risk of delayed bleeds or just chance it?
I’ve been intrigued by the idea of delayed imaging in these patients for a while. I tend to CT when they hit the door then observe for a few hours before d/c. I think my neurosurgeons might stroke out if I called them with a positive study that had been in the ER for 6+ hours. My rads would likewise bleed into their brain if they had to read a study at Tzero and T6hours. I’d like to hear what the community thinks?
Anyways, sorry to hijack, but in regards to this lecture, I found it practice-changing, and legit speaker of the year material.
Thanks!
Yep, two cts are tough. I think the argument to make to the neurosurgeons is that in a pt with a perfect mental status, there is no way they would have rushed to intervention anyway.
Obviously if your pretest is high, you need to get the zero hour ct, but unfortunately those are the pts most likely to have the delayed bleed.
At many centers on the west coast, including mine, it is the practice to obtain a delayed (4-6 hour) CT on minor head trauma patients on Coumadin with INRs >1.5. One trauma center in our town admits all for 24 hours. At my place, we keep them in the ED and repeat the CT. If they are supratherapeutic with INR > 3-4, those patients get admitted by the trauma service. Not alot of science behind this but it is a common practice in my community. We follow a similar pattern for patients on Plavix but are inconsistent with aspirn patients.http://blog.emcrit.org/wp-content/plugins/wp-notcaptcha/lib/vertical_sign.png
Anthony,
That is excellent info!
Scott
Anthony,
That’s good to know. I think that’s great patient care. that’s far from the current practice in my shop, unfortunately, but hopefully we can change some minds along the way.
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