Thrombocytopenia with SPLEEN rupture after MVA. - triplehelix

[ArchivalUser]

309.
You are asked to consult on a 34-year-old male with thrombocytopenia. He sustained a motor
vehicle collision 10 days ago, resulting in shock, internal bleeding, and acute renal failure. An
exploratory laparotomy was performed that showed a ruptured spleen requiring a splenectomy.
He also underwent an open reduction and internal fixation of the left femur. The platelet count
was 260,000 cells/L on admission. Today it is 68,000 cells/L. His medications are oxacillin,
morphine, and subcutaneous heparin. On examination the vital signs are stable. The
examination is significant for an abdominal scar that is clean and healing. The patient's left leg
is in a large cast and is elevated. The right leg is swollen from the calf downward. Ultrasound of
the right leg shows a deep venous thrombosis. Antiheparin antibodies are positive. Creatinine is
3.2 mg/dL. What is the most appropriate next management step?
B. Stop heparin and start enoxaparin.
C. Stop heparin and start argatroban.
D. Stop heparin and start lepirudin.
E. Observe the patient.

[ArchivalUser]

DD

[ArchivalUser]

cccccccccc

[ArchivalUser]

DDDD

[ArchivalUser]

The action to be taken when there is HIT is not an easy decision. [14] All LMW heparins are contraindicated. Danaparoid (Orgaran) made of dermatan sulphate and chondroitin is a factor Xa inhibitor that is structurally distinct from heparin. Experience is limited and it is expensive and it causes prolonged anticoagulation. The direct thrombin inhibitor from the leech called hirudin [15] or lepuridin is costly too. Argotroban thrombin inhibitor is available commercially. The APTT is used for control, or the ecarin clotting time. [16]

tough choice .....between C and D

I would go with C i guess

[ArchivalUser]

D. Stop heparin and start lepirudin.

http://www.medscape.com/viewarticle/463457_3

[ArchivalUser]

c is the answer as it is metabolised by liver ,while lepirudineis renally metabolosed so contraindicated in this patient

[ArchivalUser]

the choice in this case is easy: if someone speaks the word "HIT" out loud, you should stop heparin unless HIT can be safely excluded.
Argatroban should be used, as lepirudin is excreted renally (patient has acute renal failure). This is what textbooks say. But: a patient in the ICU w/ renal failure is likely treated w/ continuous veno-venous hemofiltration (polysulvone membranes are more lepirudin-permeable than AN69)! Lepirudin can be used in this case, but as stualis pointed out, the ecarin clotting time has to be checked (in addition to aPTT)!

© for USMLE sake

[ArchivalUser]

triple helix kindly do answer the qs I posted about cheap places in cleveland, OH

THANKS

[ArchivalUser]

probably TH lives in a nice neighborhood...not a cheap place!!!