Heme/Onc

80 yo lady presents with a hematoma after a fall

Mary Guan on Jan 22, 2019 - University of Michigan

Ms. Brown experienced a hematoma and fall while on coumadin, so the team is unsure whether she should restart anticoagulation right now. Anticoagulation is currently being held. Additionally, although her baseline hemoglobin is 12, her HGB have been consistently in the 7-8 range since the I+D of the hematoma, necessitating multiple blood transfusions. The question arises whether Ms. Brown has an underlying anemia that is causing her HGB to remain low with the multiple blood transfusions.

To work up Ms. Brown's anemia, what lab tests would you order?

Select all that apply
Expand all answers
LDH and Haptoglobin
Yes, this is possible, given her mechanical mitral valve and the possibility of shearing, although there is little concern for a leaky valve at this time.


Iron studies
Yes, this is possible.


Stool guiac
Unlikely as patient does not report GI bleeding


Vitamin B12 and folate
Yes this is possible, especially in the elderly with questionable nutrition.


Reticulocyte count
Yes, what would this tell you about her anemia?


Anemia labs come back all WNL, so at this point the team believes her anemia to be due to her bleed from the hematoma and iatrogenic from the I+D in the OR.

At the same time, the primary team decides to consult cardiology for recommendations on anticoagulation given her mechanical mitral valve and atrial fibrillation.

What is Ms. Brown's CHADS-VASC2 score?

Expand all answers
1
No please try again


2
No please try again


3
No please try again


4
Correct! She gets 4 points from age (+2), sex (+1), and history of hypertension (+1).


5
No please try again


Her CHADS-VASC2 score puts her at a stroke risk of 4.8% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 6.7% risk of stroke/TIA/systemic embolism. Any score greater than or equal to 2 puts the patient at moderate to high risk of stroke and should be anticoagulated.

What are some other elements of Ms. Brown's history that would argue for restarting anticoagulation?

Select all that apply
Expand all answers
Her mechanical mitral valve
Yes.


Hyper-coagulable state
No, this is not part of her history.


Atrial fibrillation
Yes.


Her CHADS-VASC2 score
Yes.


History of VTE
No, this is not part of her history.


  1. Colantino, A., Jaffer, A., Brotman, D. (2015). Resuming anticoagulation after hemorrhage: A practical approach. Cleveland Clinic Journal of Medicine, 82(4):245-256.
  2. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010). Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest, 137(2):263-72.

Ms. Brown experienced a hematoma and fall while on coumadin, so the team is unsure whether she should restart anticoagulation right now. Anticoagulation is currently being held. Additionally, although her baseline hemoglobin is 12, her HGB have been consistently in the 7-8 range since the I+D of the hematoma, necessitating multiple blood transfusions. The question arises whether Ms. Brown has an underlying anemia that is causing her HGB to remain low with the multiple blood transfusions.

To work up Ms. Brown's anemia, what lab tests would you order?

Select all that apply
Expand all answers
LDH and Haptoglobin
Yes, this is possible, given her mechanical mitral valve and the possibility of shearing, although there is little concern for a leaky valve at this time.


Iron studies
Yes, this is possible.


Stool guiac
Unlikely as patient does not report GI bleeding


Vitamin B12 and folate
Yes this is possible, especially in the elderly with questionable nutrition.


Reticulocyte count
Yes, what would this tell you about her anemia?


Anemia labs come back all WNL, so at this point the team believes her anemia to be due to her bleed from the hematoma and iatrogenic from the I+D in the OR.

At the same time, the primary team decides to consult cardiology for recommendations on anticoagulation given her mechanical mitral valve and atrial fibrillation.

What is Ms. Brown's CHADS-VASC2 score?

Expand all answers
1
No please try again


2
No please try again


3
No please try again


4
Correct! She gets 4 points from age (+2), sex (+1), and history of hypertension (+1).


5
No please try again


Her CHADS-VASC2 score puts her at a stroke risk of 4.8% per year in >90,000 patients (the Swedish Atrial Fibrillation Cohort Study) and 6.7% risk of stroke/TIA/systemic embolism. Any score greater than or equal to 2 puts the patient at moderate to high risk of stroke and should be anticoagulated.

What are some other elements of Ms. Brown's history that would argue for restarting anticoagulation?

Select all that apply
Expand all answers
Her mechanical mitral valve
Yes.


Hyper-coagulable state
No, this is not part of her history.


Atrial fibrillation
Yes.


Her CHADS-VASC2 score
Yes.


History of VTE
No, this is not part of her history.


  1. Colantino, A., Jaffer, A., Brotman, D. (2015). Resuming anticoagulation after hemorrhage: A practical approach. Cleveland Clinic Journal of Medicine, 82(4):245-256.
  2. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010). Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest, 137(2):263-72.

409  views

  0 likes

      0 comments