Bleeding

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Slide 1 : Bleeding Case presentation Jiri Pavlu, M.D.
Slide 2 : 26 yrs old lady from south India 11 months in the UK computer programmer single, lives with friends vegan previously well on no medications Background
Slide 3 : Nausea and vomiting one day sudden onset Abdominal and back pain stabbing in character Bleeding gums and nose haematuria Presentation
Slide 4 : Examination Looked dry Bleeding gums Epistaxis stopped spontaneously Weight 50kg No sighs of malnutrition
Slide 5 : Blood tests Full blood count Hb 14.6, WCC 12.1, Plt 347 Coagulation PT >150 s APTT 91.5 s fibrinogen (Clauss) 4.5 g/L thrombin time 11.5 s [9.0 - 12.6] [22.0 - 32.0] [1.7 - 4.2] [10.7 - 16.3]
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Slide 7 : Blood tests Biochemistry Na 134, K 4.4, urea 3.8, creatinine 122, cCa 2.11, Total bilirubin 6, ALP 71, ALT 16, albumin 40, GGT 36 CRP 113
Slide 8 : Blood tests Biochemistry Na 134, K 4.4, urea 3.8, creatinine 122, cCa 2.11, Total bilirubin 6, ALP 71, ALT 16, albumin 40, GGT 36 CRP 113 Na 134, K 4.4, urea 3.8, creatinine 122, cCa 2.11, Total bilirubin 6, ALP 71, ALT 16, albumin 40, GGT 36 CRP 113
Slide 9 : ? impression investigations management ?
Slide :
Slide 11 : Factor levels F X 1.3 F V 118.0 F VII 3.5 Coagulation F X 1.3 [50.0 - 200.0] F V 118.0 [50.0 – 150.0] F VII 3.5 [50.0 - 150.0]
Slide 12 : Factor levels F X 1.3 F V 118.0 F VII 3.5 Coagulation F X 1.3 [50.0 - 200.0] F V 118.0 [50.0 – 150.0] F VII 3.5 [50.0 - 150.0]
Slide 13 : Factor levels F X 1.3 F V 118.0 F VII 3.5 Coagulation Vitamin K1 (phylloquinone) F X 1.3 [50.0 - 200.0] F V 118.0 [50.0 – 150.0] F VII 3.5 [50.0 - 150.0]
Slide 14 : Adequate adult intake: 90 – 120 mcg/day
Slide 15 : vitamin K – 10 mg i.v. intravenous fluids antiemetics - metoclopramide painkillers – tramadol calcium Management ultrasound abdomen and pelvis normal findings Investigations
Slide 16 : Blood tests 12 hours later Coagulation PT 52.9 s [9.0 - 12.6] INR 5.0 [0.8 - 1.2] APTT 59.3 s [22.0 - 32.0] fibrinogen (Clauss) 4.2 g/L [1.7 - 4.2] thrombin time 11.5 s [10.7 - 16.3]
Slide 17 : Blood tests 36 hours later After another 10 mg of vitamin K(total 20mg) Coagulation PT 59.2 s [9.0 - 12.6] INR 5.7 [0.8 - 1.2] APTT 52.4 s [22.0 - 32.0]
Slide 18 : http://www.banksy.co.uk
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Slide 21 : Superwarfarin poisoning Increase of vitamin K dose to 100mg per day orally Brodifacoum detected in serum Level 0.86 mg/l
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Slide 23 : Superwarfarin action vitamin K epoxide inactive proteins ?-carboxylated proteins vitamin K quinonone qunone reductase vitamin K depencent carboxylase epoxide reductase vitamin K quinol
Slide 24 : Superwarfarin action vitamin K epoxide inactive proteins ?-carboxylated proteins vitamin K quinonone qunone reductase vitamin K depencent carboxylase epoxide reductase vitamin K quinol
Slide 25 : Superwarfarin action vitamin K epoxide inactive proteins ?-carboxylated proteins vitamin K quinonone qunone reductase vitamin K depencent carboxylase epoxide reductase vitamin K quinol
Slide 26 : Superwarfarin action vitamin K epoxide inactive proteins ?-carboxylated proteins vitamin K quinonone qunone reductase vitamin K depencent carboxylase epoxide reductase vitamin K quinol
Slide 27 : Superwarfarin action vitamin K epoxide inactive proteins ?-carboxylated proteins vitamin K quinonone qunone reductase vitamin K depencent carboxylase epoxide reductase vitamin K quinol
Slide 28 : Superwarfarins Second generation anticoagulant rhodenticides Developed to overcome warfarin resistance recognized in late 60’s in rats not humans inherited genetic characteristic, not acquired during the lifetime warfarin-resistant alleles are very rare until selection with warfarin has been practised for several years
Slide 29 : Superwarfarins Lipid soluble concentrate in liver elimination half life is estimated to last anywhere form weeks to months antidote – prolonged administration of very high doses of vitamin K
Slide 30 : Brodifacoum As other superwarfarins it is sold under no restrictions HavocKleratSorexa CheckatubeTalonNofar Should be used indoors – environmental risks LD50 rat 0.4, rabbit 0.2, dog 0.25-3.6 mg/kg
Slide 31 : Learning points Superwarfarins may cause lethal haemorrage in both rats and humans Diagnosis is based on history coagulation results consistent with vitamin K defficiency limited and transient response to standard doses of vitamin K
Slide 32 : Learning points The elimination of superwarfarins canlast weeks or months prolonged treatment and monitoring is necessary Watch what you eat
Slide 33 : Learning points The elimination of superwarfarins canlast weeks or months prolonged treatment and monitoring is necessary Watch what you eat
Slide 34 : The end
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