Transfusion
89 years old F Afib on Wafarin, fell, hit her head on the ground, CT head, subdural hematoma. INR 4,9, IV vit K was given, what next for reverse anticoagulation?
PPC
57 years old F admitted for sepsis from necrotizing pancreatitis, Day 5, diffuse petechia, blood leaking from IV, foley, melena. What do you expect from PTT, PT, Platelet, fibrin degradation product
Decrease PT/PTT/ Plt/ increase Fibrin degradation product
Young man has MVA, active hemorrhage, What is the ratio of packed RBCs to plasma and platelets recommended in the patient’s initial resuscitation?
RBC: Plasma: Platelet 1:1:1
32 years old M has MVA 14 hours ago Pelvic fracture, Pulmonary contusion, admitted to ICU, no ongoing bleeding, Hgb stable. What is the VTE prophylaxis
enoxaparin , monitor Xa
A 64-year-old patient experiences a mechanical fall at home. 8-mm subdural hematoma with midline shift. Neurosurgery is consulted and believes she would benefit from a craniectomy. A preoperative laboratory report indicates WBCs 10,300/µL, Hgb 7.0 g/dL, Hct 21.4%, platelets 38,000/µL, PT 12.0 seconds, aPTT 40.0 seconds, and INR 1.0. What blood product would reduce her risk of bleeding?
platelet
An 82-year-old woman suffers an intraparenchymal hemorrhage after a fall. She is found 1 day later to have a femoral deep vein thrombosis. How should this be managed?
IVC
What factor is deficiency in hemophilia A, B. what test to measure?
A: factor 8
B factor 9
PTT test
A 51-year-old patient is admitted for an anemia workup. Her Hgb is 6.3 mg/dL on presentation, so she is consented for blood transfusion. In the first 60 minutes of her transfusion, she reports feeling warm and jittery, and her temperature is 38.2 °C. She remains hemodynamically stable. What is the best next step in the management of this woman’s suspected febrile nonhemolytic transfusion reaction?
Stop the transfusion
A 37-year-old woman presents to the general surgery clinic for evaluation for laparoscopic cholecystectomy. On review of systems, she mentions that she tends to bleed easily and has significant menstrual bleeding but never really thought much about it because it runs in her family. What test is most specific for diagnosis of this bleeding disorder?
Von Willebrand disease antigen
A 72-year-old woman BMI of 42 , AFib on rivaroxaban presents to the surgery clinic with new-onset abdominal pain. The pain is primarily located in the right mid abdomen and is not associated with nausea or emesis. The patient underwent a laparoscopic appendectomy 3 weeks ago for uncomplicated acute appendicitis. On physical examination, the incision sites are nontender and non erythematous. A firm, tender mass is palpated to the right of the umbilicus. A CT reveals a small spindle-shaped mass posterior to the rectus abdominus. Which of the following is the strongest risk factor in this patient’s diagnosis?
Therapeutic anticoagulation
72-year-old woman undergoes an open distal pancreatectomy and splenectomy for chronic pancreatitis. She develops a symptomatic femoral deep vein thrombosis diagnosed postoperatively. For how long should she be treated with anticoagulation?
3 months
A 38-year-old patient arrives in the ED complaining of abdominal pain. Her history includes peptic ulcer disease but is otherwise negative. Plain films demonstrate free air. She remains hemodynamically stable. Laboratory studies reveal a platelet count of 45,000/µL and a normal prothrombin time/partial thromboplastin time. What is the most appropriate next step in the management?
Transfusion of platelets to a goal of 50,000/µL
A 37-year-old man is 1 day into his hospital stay for a blunt assault from which he has several rib fractures. He has been receiving low-molecular-weight heparin, and his team would like him to get an epidural. How long should the team wait after the last dose of prophylactic dose of low-molecular-weight heparin before placing such a catheter?
12 hours
A 24-year-old patient sustains two gunshot wounds to the right chest. A right chest tube is placed in the trauma bay with immediate return of 2 liters of blood. A massive transfusion protocol is activated, and he is taken urgently to the OR for a right anterolateral thoracotomy. During his resuscitation in the OR, he receives 12 units of packed RBCs, 12 units of fresh frozen plasma, and 2 units of platelets. This man is at great risk for which of the following electrolyte abnormalities?
Hypocalcemia
A 40-year-old man undergoes abdominoperineal resection for a distal rectal cancer. For how long should he receive venous thromboembolism chemoprophylaxis?
4 weeks
A 45-year-old patient undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The operation is complicated by significant blood loss from an inadvertent transection of the cystic artery, which takes some time to control. The following day, she complains of incisional pain that is well controlled; she is otherwise asymptomatic. Vital signs are WNL. Postop Hgb is 9 g/dL, decreased from a baseline of 12 g/dL. The nurse asks about possible blood transfusion. What is the most appropriate next step in management?
No further treatment
A 63-year-old woman with von Willebrand disease is scheduled to undergo a laparoscopic cholecystectomy for symptomatic cholelithiasis. Which of the following agents administered in the preoperative area is most likely to reduce blood loss during the procedure?
Desmopressin
A 46-year-old patient is admitted to the ICU for management of diabetic ketoacidosis. Her platelet count is 178,000/µL. She is placed on subcutaneous heparin for deep venous thrombosis prophylaxis. She has a prolonged hospital course and develops pneumonia. On hospital day 6, her platelet count is 18,000/µL. She is placed on piperacillin-tazobactam and started on continuous renal replacement therapy for kidney failure. When evaluating this woman for potential heparin-induced thrombocytopenia, which of the following is a clinical consideration?
Onset of platelet decrease within 5 to 10 days of initial heparin exposure
A 35-year-old man with multiple gunshot wounds to the abdomen recently underwent surgery requiring massive transfusion and a damage control procedure. He arrives at the surgical ICU with blood oozing from his nose and wounds. What is the best test to order to help determine what products to give to correct this man’s coagulopathy?
Thromboelastography TEG
A 22-year-old man is involved in a motor vehicle crash and is intubated in the field. He is taken to the operating room for hemodynamic instability and is found to have a liver laceration, which is repaired. Overnight, his wound vac system continues to put out a large amount of bloody fluid from his open abdomen. PMH of von Willebrand disease (vWD). In addition to low levels of factor VIII, what is the underlying pathophysiology of vWD causing the ongoing bleeding in this patient?
Failure of platelets to adhere to injured vessel wall
A transfusion of 1 unit of packed RBCs is ordered for a 70-year-old patient who is POD 1 from L hip arthroplasty for Hgb of 6.8 g/dL. Thirty minutes after the transfusion begins, the patient develops rigors and shortness of breath. He quickly becomes obtunded with notable stridor. Vital signs are significant for HR 120 beats/min, BP 100/60 mm Hg, respiratory rate 35 beats/min, and oxygen saturation 83%. After stopping the infusion, which of the following is the most appropriate next step in the management of this patient?
Intubate the patient and ensure adequate IV access.
A 53-year-old woman with no previous hospitalization presents to the emergency department with signs of a perforated duodenal ulcer and new-onset Afib. She undergoes open repair with a vascularized omental pedicle and is started on heparin infusion in the postoperative period. On POD 5, she develops areas of skin necrosis. Laboratory evaluation shows that her platelet count is now 45,000/µL, down from 155,000/µL on previous tests. What is the appropriate treatment for this condition?
Stopping the heparin infusion and starting argatroban
A 35-year-old patient is postoperative day 1 after a laparotomy for trauma. He does not have any recent anticoagulant use. His hematocrit continues to downtrend, and thromboelastography is performed. The alpha angle is 45 degrees. Which of the following is the best management for this patient’s coagulopathy?
Cryoprecipitate
In thromboelastography, the alpha angle is the measure of the angle tangent to the curve at K, the point of initial clot formation. This represents the rate at which the clot propagates, involving the build-up and cross-linking of fibrin. Normal alpha values range from 53 to 72 degrees. Values less than 53 degrees represent a malfunction in fibrinogen, the treatment for which is cryoprecipitate.
A 53-year-old woman is now postoperative day 10 following a Whipple procedure for pancreatic ductal adenocarcinoma, and she develops a petechial rash. Routine laboratory evaluation is significant for an acute decrease in her platelet count from 150,000/µL to 40,000/µL. She receives a diagnosis of heparin-induced thrombocytopenia. Which of the following is the appropriate management of this condition?
Discontinue unfractionated heparin and begin a direct thrombin inhibitor.
A 32-year-old woman with history of Crohn disease, oral contraceptive use, and deep vein thrombosis on dabigatran presents for follow-up with her primary care physician. Laboratory work is notable for an INR of 3.1. Part of her workup for this abnormal laboratory value should be which of the following?
Magnetic resonance cholangiopancreatography