To Clot Or Not To Clot…

Emergency Care for Coagulation Disorders/Conditions

Rebecca Goldsmith Pediatric Thrombosis/Hemophilia Nurse

McMaster Children’s HospitalCurrent Concept in Pediatrics

October 16th, 2009

Objectives

Virchow’s TriadReasons for referrals Line related DVTsAnticoagulation of DVTsCase study – keypad questionClinic informationQuestions

Virchow’s Triad

Blood flow (stasis)

Vessel Blood Wall Components

Reasons for Referrals

Prothrombotic workupDeep Vein Thrombosis (DVT)Pulmonary Embolism (PE)StrokeFracture prophylaxisArterial thrombosis

Reasons for Anticoagulation

DVT Cardiac prophylaxis(BT shunt, Fontan

procedure, Norwood procedure) Fracture prophylaxis Arterial clot Hereditary prothrombotic states Stroke (pediatric pts. cerebral sinovenous

thrombosis, CSVT) however, there is not a lot of evidence to support this

Line related DVTs

Clinical observation• CVL dysfunction• Limb or facial swelling distal to a CVL

insertion site• Superficial new collateral vein

development• Pain, swelling, or redness in limb• Abdominal pain +/- fever without other

explanation

Confirmation of limb DVT can be made with

- Compression Doppler U/S - Venogram - MRV

Treatment Options

LMWH

Advantages Disadvantage

* Subcutaneous injections daily or twice daily

minimal monitoring required

reduced risk of interaction with other medication or diet

reduced risk of heparin induced thrombocytopenia (HIT)

probable reduced risk of osteoporosis in long-term

Warfarin Therapy

Advantages

Taken per os no injections

Disadvantages *Therapeutic range of INR must be in place at least two consecutive days prior to removing LMWH

* many drug interactions (ex. Antibiotics)

* interacts with diet high in Vitamin K enriched foods

*reduced bone density in pts taking warfarin for more than one year

Case Study Question-

A 17 yr old female presents in ER. She appears anxious, sweating. She has a rapid HR and low BP. c/o sharp chest pain and shortness of

breath. She admits to taking oral contraceptive pills for three months.

You suspect which of the following?

1. Myocardial infarct 2. Pulmonary embolism3. Pregnancy4. Panic Attack

Pulmonary embolism

Confirm diagnosis with ventilation-perfusion scan

Clinic Information

Pediatric Thrombosis ClinicHamilton Health Sciences1200 Main St WestHamilton905-521-2100 ex 75970

References

Monagle, P., Chan, A.K.C., deVeber, G, Massicotte, M.P. (2006).Pediatric Thromboemolism and Stroke (3rd ed.). Hamilton, ON: B.C. Decker Inc.

Resources:Machealth.caThrombosis Interest Group of Canada

http://www.tigc.org/