A*******s
发帖数: 9638 | 1 昨天晚上睡得晚， 3am医院ICU page我， 我迷迷糊糊打电话， 刚说我不oncall，对方
说了个名字，我一下子全醒了。
这个病人是我的一个老病人， 在医院工作，67岁，她有osler-weber-rendu disease，
epistaxis是常事， 最近出现A-Fib， 因为coumadin引起出血， 所以不能服。
一个星期以后， 她出现中风，因为出血的原因， 不能上heparin， 第二天她在医院又出现右手臂动脉栓塞。 所幸手术后没事。 没办法，她需要抗凝， 所以开始服用Pradaxa。
出院后epistaxis似乎没大问题， 没想到她出现贫血， 血色素只有6。 入院后输血， Pradaxa只能停掉。
(中文太难打了。。。）
I started her on heparin. Consulted GI/Surgery for endoscopy. Surgery did
the upper and lower GI scope and I was told she has possible AVM but no
active bleeding.
I do not know how to differentiate AVM from telangiectasia just by looking.
Cardiology put her back on pradaxa last night. But she had a massive stroke
at 11pm.
What are you going to do with her? I am stuck. |
s******t
发帖数: 579 | 2 I have been thinking about this kind of dilemmas a lot times and everytime I
felt nervous about it. If I face that kind of situation in the future, I
don't know what should I do.
Is it true that the doctors deal with life threatening situation first then,
thinking about others? Do we have a better approach for this situation? |
A*******s
发帖数: 9638 | 3 Risks over benefits.
You are absolutely right. We need to take care of the critical issues first
. In her case, after stroke happened , I had to prevent her from recurrent
stroke first and took the chance of epistaxia.
I believe she had internal bleeding other than epistaxia after being on
Pradaxa.
But just being off heparin several hours for endoscopy, she had another
stroke.
I am helpless.
I
then,
【在 s******t 的大作中提到】
: I have been thinking about this kind of dilemmas a lot times and everytime I
: felt nervous about it. If I face that kind of situation in the future, I
: don't know what should I do.
: Is it true that the doctors deal with life threatening situation first then,
: thinking about others? Do we have a better approach for this situation?
|
y******a
发帖数: 590 | 4 I will not put her on oral anticoagulation. She has a history of epistaxis,
and GI bleed from AVM, it is possible that she has AVMs in her brain.
anticoagulation may put her at higher risk of ICH, not only GI bleed. |
A*******s
发帖数: 9638 | 5 But she was having emboli. 2 events within 2 days! One in the brain and the
other in the arm.
epistaxis,
【在 y******a 的大作中提到】
: I will not put her on oral anticoagulation. She has a history of epistaxis,
: and GI bleed from AVM, it is possible that she has AVMs in her brain.
: anticoagulation may put her at higher risk of ICH, not only GI bleed.
|
y******a
发帖数: 590 | 6 There is a new score published by British last year, HAS-BLED score, in
conjunction with CHA2DS2-VAS score to assess the one year risk of major
bleeding event vs. stroke.
link: http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk
I don't know if it will help. But anyway, in her case I will not start OAC.
Any uncorrectable conditions predisposing pt to bleed are
contraindications.
the
【在 A*******s 的大作中提到】
: But she was having emboli. 2 events within 2 days! One in the brain and the
: other in the arm.
:
: epistaxis,
|
A*******s
发帖数: 9638 | 7 I am aware of the study. Thanks for the link.
Her CHA2DS2-vasc score is 4, same as HAS-BLED Score. Risks for stroke and
bleeding are 2% and 8% respectively. But we can not only use the numbers.
These numbers tell us she is on high risks for stroke as well as bleeding.
She was not started on OAC after being found to have A-fib. After she had
the stroke, she was not started on heparin either. But on the 2nd day of stroke, she had
the 2nd emboli to right arm. Then she was started on heparin. After surgery
, she was discharged to home.
I did not have the gut not to put her on OAC at discharge. She told me she
regreted not being on coumadin prior to the stroke.
The fact is, she did not have a stroke after discharge. Bleeding is likely reversible but stroke is not.
One stroke is 2 points, one stroke plus one peripheral artery emboli within
2 days should be 10 points in my opinion.
OAC.
【在 y******a 的大作中提到】
: There is a new score published by British last year, HAS-BLED score, in
: conjunction with CHA2DS2-VAS score to assess the one year risk of major
: bleeding event vs. stroke.
: link: http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk
: I don't know if it will help. But anyway, in her case I will not start OAC.
: Any uncorrectable conditions predisposing pt to bleed are
: contraindications.
:
: the
|
y******a
发帖数: 590 | 8 Does she have other/new conditions that put her at higher risk of getting
thromoemboli? Any detectable thrombus in her heart? I am just curios. As
you said, she clearly expressed her preference regarding OAC, so help her to
make an informed decision. |
A*******s
发帖数: 9638 | 9 Age, female. That's it. She was pretty healthy until the A-fib.
No coagulopathy and TTE was neg. No TEE since she would be on Pradaxa
anyway.
She understood the risks prior to be on anticoagulations including heparin. |
r********n
发帖数: 48 | 10 If she just had a massive stroke, the immediate problem might be life or
death, rather than anticoag or not. If massive stroke, I would not start
anti coag at least in the next few days. But family has to know the
consequence if she suffer another stroke. Then if she survive this, to make
a decision about anticoag, I would discuss with her in detail the risk and
benifits, give her all the numbers to help her make an informed decision.
Doctors are not god. I had a similar case before. I remeber my attending
said, it is just a matter how he wants to die. This is a cruel saying but
this is the truth. I feel the most important thing is to keep the patient
and family informed. My two cents... |
|
|
A*******s
发帖数: 9638 | 11 In her case, for the first stroke, no heparin, sure.
But for the second stroke, I have no other choices. She was not a TPA
candidate.
Again, risks over benefits.
The patient and family should always be informed prior to the initiation of
anticoagulation.
make
【在 r********n 的大作中提到】
: If she just had a massive stroke, the immediate problem might be life or
: death, rather than anticoag or not. If massive stroke, I would not start
: anti coag at least in the next few days. But family has to know the
: consequence if she suffer another stroke. Then if she survive this, to make
: a decision about anticoag, I would discuss with her in detail the risk and
: benifits, give her all the numbers to help her make an informed decision.
: Doctors are not god. I had a similar case before. I remeber my attending
: said, it is just a matter how he wants to die. This is a cruel saying but
: this is the truth. I feel the most important thing is to keep the patient
: and family informed. My two cents...
|
a*******n
发帖数: 82 | 12 If her TTE is unremarkable, I would do TEE and shock her out of AF on the
condition of no clots in atrium. And I don't like Pradaxa. I just had a case
of fatal pulmonary hemorrhage with Pradaxa. |
A*******s
发帖数: 9638 | 13 A new drug. So far I had no problem with it. I only use it when the
patient could not take coumadin.
case
【在 a*******n 的大作中提到】
: If her TTE is unremarkable, I would do TEE and shock her out of AF on the
: condition of no clots in atrium. And I don't like Pradaxa. I just had a case
: of fatal pulmonary hemorrhage with Pradaxa.
|
A*******s
发帖数: 9638 | 14 The patient passed away last night, died of intracranial bleeding after
Friday's massive stroke.
I still remember clearly she was joking with me on Friday. She was 67 yrs
old, a respiratory therapist and could not afford retiring according to her.
A sad day. |
f******w
发帖数: 10267 | 15 pat pat。你已经尽了全力了。我原来的邻居，家族有心血管疾病史，她一直在
coumadin上，两年前的春天，得UTI尿血很厉害，医生就把coumadin拿掉了，老太太几
周以后stroke，还好送医院后病情控制住保了一条命，但是大脑严重受损，语音能力基
本没有了。
her.
【在 A*******s 的大作中提到】
: The patient passed away last night, died of intracranial bleeding after
: Friday's massive stroke.
: I still remember clearly she was joking with me on Friday. She was 67 yrs
: old, a respiratory therapist and could not afford retiring according to her.
: A sad day.
|
y******a
发帖数: 590 | 16 thank you for the update. A sad case.
BTW, is there any recommendation or study regarding the risk of hemorrhagic
conversion after a massive ischemic
stroke? When is the safe time to start anticoagulation?
her.
【在 A*******s 的大作中提到】
: The patient passed away last night, died of intracranial bleeding after
: Friday's massive stroke.
: I still remember clearly she was joking with me on Friday. She was 67 yrs
: old, a respiratory therapist and could not afford retiring according to her.
: A sad day.
|
A*******s
发帖数: 9638 | 17 No heparin for any strokes. For a-fib, it depends.
hemorrhagic
【在 y******a 的大作中提到】
: thank you for the update. A sad case.
: BTW, is there any recommendation or study regarding the risk of hemorrhagic
: conversion after a massive ischemic
: stroke? When is the safe time to start anticoagulation?
:
: her.
|
y******a
发帖数: 590 | 18 I probably didn't ask the questions in a clear way. My question is, if pt
does have a condition require anticoagulation, when would you start it after
the stroke? for example, if a pt came in with a massive MCA ischemic
stroke, and a newly identified a fib, when is the appropriate time to give
heparin/coumadin, considering the risk of hemarrhagic conversion? and will
you give both aspirin and plavix for anti platelet agent or only one of them
? I am not a neurologist, but my experience with the stroke team in my
hospital kind of make me feel that there is no evidence based guideline
regarding this issue. |
A*******s
发帖数: 9638 | 19 Usually start coumadin within 2 wks after a massive infarct with a-fib. There
is a guideline for this.
Avoid anticoagulation for any new massive infarct. But it depends.
after
will
them
【在 y******a 的大作中提到】
: I probably didn't ask the questions in a clear way. My question is, if pt
: does have a condition require anticoagulation, when would you start it after
: the stroke? for example, if a pt came in with a massive MCA ischemic
: stroke, and a newly identified a fib, when is the appropriate time to give
: heparin/coumadin, considering the risk of hemarrhagic conversion? and will
: you give both aspirin and plavix for anti platelet agent or only one of them
: ? I am not a neurologist, but my experience with the stroke team in my
: hospital kind of make me feel that there is no evidence based guideline
: regarding this issue.
|
A*******s
发帖数: 9638 | 20 昨天晚上睡得晚， 3am医院ICU page我， 我迷迷糊糊打电话， 刚说我不oncall，对方
说了个名字，我一下子全醒了。
这个病人是我的一个老病人， 在医院工作，67岁，她有osler-weber-rendu disease，
epistaxis是常事， 最近出现A-Fib， 因为coumadin引起出血， 所以不能服。
一个星期以后， 她出现中风，因为出血的原因， 不能上heparin， 第二天她在医院又出现右手臂动脉栓塞。 所幸手术后没事。 没办法，她需要抗凝， 所以开始服用Pradaxa。
出院后epistaxis似乎没大问题， 没想到她出现贫血， 血色素只有6。 入院后输血， Pradaxa只能停掉。
(中文太难打了。。。）
I started her on heparin. Consulted GI/Surgery for endoscopy. Surgery did
the upper and lower GI scope and I was told she has possible AVM but no
active bleeding.
I do not know how to differentiate AVM from telangiectasia just by looking.
Cardiology put her back on pradaxa last night. But she had a massive stroke
at 11pm.
What are you going to do with her? I am stuck. |
|
|
s******t
发帖数: 579 | 21 I have been thinking about this kind of dilemmas a lot times and everytime I
felt nervous about it. If I face that kind of situation in the future, I
don't know what should I do.
Is it true that the doctors deal with life threatening situation first then,
thinking about others? Do we have a better approach for this situation? |
A*******s
发帖数: 9638 | 22 Risks over benefits.
You are absolutely right. We need to take care of the critical issues first
. In her case, after stroke happened , I had to prevent her from recurrent
stroke first and took the chance of epistaxia.
I believe she had internal bleeding other than epistaxia after being on
Pradaxa.
But just being off heparin several hours for endoscopy, she had another
stroke.
I am helpless.
I
then,
【在 s******t 的大作中提到】
: I have been thinking about this kind of dilemmas a lot times and everytime I
: felt nervous about it. If I face that kind of situation in the future, I
: don't know what should I do.
: Is it true that the doctors deal with life threatening situation first then,
: thinking about others? Do we have a better approach for this situation?
|
y******a
发帖数: 590 | 23 I will not put her on oral anticoagulation. She has a history of epistaxis,
and GI bleed from AVM, it is possible that she has AVMs in her brain.
anticoagulation may put her at higher risk of ICH, not only GI bleed. |
A*******s
发帖数: 9638 | 24 But she was having emboli. 2 events within 2 days! One in the brain and the
other in the arm.
epistaxis,
【在 y******a 的大作中提到】
: I will not put her on oral anticoagulation. She has a history of epistaxis,
: and GI bleed from AVM, it is possible that she has AVMs in her brain.
: anticoagulation may put her at higher risk of ICH, not only GI bleed.
|
y******a
发帖数: 590 | 25 There is a new score published by British last year, HAS-BLED score, in
conjunction with CHA2DS2-VAS score to assess the one year risk of major
bleeding event vs. stroke.
link: http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk
I don't know if it will help. But anyway, in her case I will not start OAC.
Any uncorrectable conditions predisposing pt to bleed are
contraindications.
the
【在 A*******s 的大作中提到】
: But she was having emboli. 2 events within 2 days! One in the brain and the
: other in the arm.
:
: epistaxis,
|
A*******s
发帖数: 9638 | 26 I am aware of the study. Thanks for the link.
Her CHA2DS2-vasc score is 4, same as HAS-BLED Score. Risks for stroke and
bleeding are 2% and 8% respectively. But we can not only use the numbers.
These numbers tell us she is on high risks for stroke as well as bleeding.
She was not started on OAC after being found to have A-fib. After she had
the stroke, she was not started on heparin either. But on the 2nd day of stroke, she had
the 2nd emboli to right arm. Then she was started on heparin. After surgery
, she was discharged to home.
I did not have the gut not to put her on OAC at discharge. She told me she
regreted not being on coumadin prior to the stroke.
The fact is, she did not have a stroke after discharge. Bleeding is likely reversible but stroke is not.
One stroke is 2 points, one stroke plus one peripheral artery emboli within
2 days should be 10 points in my opinion.
OAC.
【在 y******a 的大作中提到】
: There is a new score published by British last year, HAS-BLED score, in
: conjunction with CHA2DS2-VAS score to assess the one year risk of major
: bleeding event vs. stroke.
: link: http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk
: I don't know if it will help. But anyway, in her case I will not start OAC.
: Any uncorrectable conditions predisposing pt to bleed are
: contraindications.
:
: the
|
y******a
发帖数: 590 | 27 Does she have other/new conditions that put her at higher risk of getting
thromoemboli? Any detectable thrombus in her heart? I am just curios. As
you said, she clearly expressed her preference regarding OAC, so help her to
make an informed decision. |
A*******s
发帖数: 9638 | 28 Age, female. That's it. She was pretty healthy until the A-fib.
No coagulopathy and TTE was neg. No TEE since she would be on Pradaxa
anyway.
She understood the risks prior to be on anticoagulations including heparin. |
r********n
发帖数: 48 | 29 If she just had a massive stroke, the immediate problem might be life or
death, rather than anticoag or not. If massive stroke, I would not start
anti coag at least in the next few days. But family has to know the
consequence if she suffer another stroke. Then if she survive this, to make
a decision about anticoag, I would discuss with her in detail the risk and
benifits, give her all the numbers to help her make an informed decision.
Doctors are not god. I had a similar case before. I remeber my attending
said, it is just a matter how he wants to die. This is a cruel saying but
this is the truth. I feel the most important thing is to keep the patient
and family informed. My two cents... |
A*******s
发帖数: 9638 | 30 In her case, for the first stroke, no heparin, sure.
But for the second stroke, I have no other choices. She was not a TPA
candidate.
Again, risks over benefits.
The patient and family should always be informed prior to the initiation of
anticoagulation.
make
【在 r********n 的大作中提到】
: If she just had a massive stroke, the immediate problem might be life or
: death, rather than anticoag or not. If massive stroke, I would not start
: anti coag at least in the next few days. But family has to know the
: consequence if she suffer another stroke. Then if she survive this, to make
: a decision about anticoag, I would discuss with her in detail the risk and
: benifits, give her all the numbers to help her make an informed decision.
: Doctors are not god. I had a similar case before. I remeber my attending
: said, it is just a matter how he wants to die. This is a cruel saying but
: this is the truth. I feel the most important thing is to keep the patient
: and family informed. My two cents...
|
|
|
a*******n
发帖数: 82 | 31 If her TTE is unremarkable, I would do TEE and shock her out of AF on the
condition of no clots in atrium. And I don't like Pradaxa. I just had a case
of fatal pulmonary hemorrhage with Pradaxa. |
A*******s
发帖数: 9638 | 32 A new drug. So far I had no problem with it. I only use it when the
patient could not take coumadin.
case
【在 a*******n 的大作中提到】
: If her TTE is unremarkable, I would do TEE and shock her out of AF on the
: condition of no clots in atrium. And I don't like Pradaxa. I just had a case
: of fatal pulmonary hemorrhage with Pradaxa.
|
A*******s
发帖数: 9638 | 33 The patient passed away last night, died of intracranial bleeding after
Friday's massive stroke.
I still remember clearly she was joking with me on Friday. She was 67 yrs
old, a respiratory therapist and could not afford retiring according to her.
A sad day. |
f******w
发帖数: 10267 | 34 pat pat。你已经尽了全力了。我原来的邻居，家族有心血管疾病史，她一直在
coumadin上，两年前的春天，得UTI尿血很厉害，医生就把coumadin拿掉了，老太太几
周以后stroke，还好送医院后病情控制住保了一条命，但是大脑严重受损，语音能力基
本没有了。
her.
【在 A*******s 的大作中提到】
: The patient passed away last night, died of intracranial bleeding after
: Friday's massive stroke.
: I still remember clearly she was joking with me on Friday. She was 67 yrs
: old, a respiratory therapist and could not afford retiring according to her.
: A sad day.
|
y******a
发帖数: 590 | 35 thank you for the update. A sad case.
BTW, is there any recommendation or study regarding the risk of hemorrhagic
conversion after a massive ischemic
stroke? When is the safe time to start anticoagulation?
her.
【在 A*******s 的大作中提到】
: The patient passed away last night, died of intracranial bleeding after
: Friday's massive stroke.
: I still remember clearly she was joking with me on Friday. She was 67 yrs
: old, a respiratory therapist and could not afford retiring according to her.
: A sad day.
|
A*******s
发帖数: 9638 | 36 No heparin for any strokes. For a-fib, it depends.
hemorrhagic
【在 y******a 的大作中提到】
: thank you for the update. A sad case.
: BTW, is there any recommendation or study regarding the risk of hemorrhagic
: conversion after a massive ischemic
: stroke? When is the safe time to start anticoagulation?
:
: her.
|
y******a
发帖数: 590 | 37 I probably didn't ask the questions in a clear way. My question is, if pt
does have a condition require anticoagulation, when would you start it after
the stroke? for example, if a pt came in with a massive MCA ischemic
stroke, and a newly identified a fib, when is the appropriate time to give
heparin/coumadin, considering the risk of hemarrhagic conversion? and will
you give both aspirin and plavix for anti platelet agent or only one of them
? I am not a neurologist, but my experience with the stroke team in my
hospital kind of make me feel that there is no evidence based guideline
regarding this issue. |
A*******s
发帖数: 9638 | 38 Usually start coumadin within 2 wks after a massive infarct with a-fib. There
is a guideline for this.
Avoid anticoagulation for any new massive infarct. But it depends.
after
will
them
【在 y******a 的大作中提到】
: I probably didn't ask the questions in a clear way. My question is, if pt
: does have a condition require anticoagulation, when would you start it after
: the stroke? for example, if a pt came in with a massive MCA ischemic
: stroke, and a newly identified a fib, when is the appropriate time to give
: heparin/coumadin, considering the risk of hemarrhagic conversion? and will
: you give both aspirin and plavix for anti platelet agent or only one of them
: ? I am not a neurologist, but my experience with the stroke team in my
: hospital kind of make me feel that there is no evidence based guideline
: regarding this issue.
|
