Questions of the Week for 3/26/2024

Author: Christian Gerhart

Q: You are caring for an 85-year-old male who presents with left sided hemiparesis. His BP on arrival is 200/140. He undergoes CT/CTA which shows a large right basal ganglia hemorrhage. He is on apixaban for atrial fibrillation and took it a few hours prior to arrival. What anticoagulation reversal agent should be considered for this patient?

  • Andexanet alfa, or if not available, prothrombin complex concentrate (PCC). Andexanet alfa is a recombinant decoy protein, which binds Factor Xa inhibitor and is specifically engineered for Factor Xa inhibitor reversal. The AHA ICH guidelines prefer Andexanet alfa though it is possible some institutions may not have this as readily available in which case PCC can be used.

Q: You are caring for an older male who presents with acute abdominal pain and is found to have an abdominal aortic aneurysm rupture. He notes that he took his apixaban earlier that morning a few hours ago. The surgical team is preparing the operating room for emergent endovascular repair, and they ask you to reverse his anticoagulation. What important characteristic should you consider when deciding on an agent?

  • Although Andexanet Alfa is generally preferred for Factor-Xa inhibitor reversal (Apixaban, Rivaroxaban), this patient is about to undergo a procedure which sometimes requires heparinization for graft placement. Andexanet Alfa is known to interfere with heparinization, which is a critical part of many endograft procedures in cardiac, vascular and neurosurgery. (4,5) This has led some authors to propose avoiding Andexanet Alfa for patients undergoing these procedures and using PCC if anticoagulation reversal is necessary. Be sure to discuss this with the surgical team prior to Andexanet administration!

Q: A 12-year-old male with no past medical history presents with 1 day of chest pain. His mother notes that he has had a cough and fevers over the past 4-5 days. His chest x ray is clear, and his EKG shows sinus tachycardia despite otherwise normal vital signs. What diagnoses should be considered?

  • There are a number of potential causes such as myocarditis, Kawasaki disease, pulmonary embolism, pneumonia, anatomical anomalies, aortic dissection and many more. For this case in particular, myocarditis, especially now that multisystem inflammatory Syndrome in Children (MIS-C) is a consideration, would be important to assess for. Myocarditis is a life-threatening cause of chest pain that is often associated with a viral prodrome. Persistent tachycardia is a concerning physical exam finding, though it is not sensitive for the diagnosis. Consider a screening troponin, and possibly MIS-C labs such as inflammatory markers, in a patient like this who has acute chest pain without another clear explanation and an abnormal EKG.

Q: You are caring for a 75-year-old male with a history of cervical spine stenosis who presents after a fall. He is complaining of neck pain and bilaterally decreased grip strength. His CT cervical spine is read as negative for acute injury but notes chronic changes from his cervical spine stenosis. What is the next best step? 

  • This patient should undergo MRI and be evaluated by a spine consultant as his neck pain and grip weakness is concerning for central cord syndrome, particularly in the setting of his cervical spine stenosis history. From the American College of Surgeons guideline, “Study authors recommended that patients with negative CT scans but persistent neurological symptoms have an MRI”. (7)

Q: You are caring for a 45-year-old male who presents after a motor vehicle collision. He was placed in a cervical collar by EMS. He complains of neck pain, chest pain and abdominal pain and undergoes CT imaging of the head, cervical spine, and chest/abdomen/pelvis. His imaging is read as negative for acute injury however he continues to complain of neck pain and has tenderness in the midline cervical spine. His full neurological examination is normal, and he is not intoxicated. He is able to fully range his neck and denies paresthesia How would you manage this case?

  • The American College of Surgeons guidelines support removal of the cervical collar in awake patients who have negative CT imaging and a normal neurological examination. However, they do leave the caveat that if the provider has continued concern for a ligamentous injury, particularly in patients with chronic degenerative changes, then an MRI can be considered. Therefore, in this case, it would probably be acceptable to remove the patient’s cervical collar as he is awake and examinable without neurological deficits and has a normal CT scan. However, if there is a high suspicion for a ligamentous injury, the patient has significant degenerative changes, or the patient has excessive pain, then further imaging can be considered. The American College of Surgeons Spinal Trauma guidelines for this are below: (7)

    “Removal of a cervical collar is recommended for adult blunt trauma patients who are neurologically asymptomatic with a negative helical cervical CT. MRI is not required for removal of a cervical collar. However, at the treating physician’s discretion, it can be considered in patients with persistent neurological symptoms, concern for ligamentous damage, high risk degenerative/pathological changes, despite a negative CT scan.”

    Check out this excellent post from the Northwestern EM blog for more: https://www.nuemblog.com/blog/cspine-clearance-ct

References:

  1. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022;53(7):e282-e361. doi:10.1161/STR.0000000000000407

  2. Pauls LA, Rathor R, Pennington BT. Andexanet Alfa-Induced Heparin Resistance Missing From SCA Blood Management in Cardiac Surgery Guidelines. J Cardiothorac Vasc Anesth. 2022;36(12):4557-4558. doi:10.1053/j.jvca.2022.07.018

  3. Samuel Heuts, Angelique Ceulemans, Gerhardus J A J M Kuiper, Jan U Schreiber, Bernard J van Varik, Renske H Olie, Hugo Ten Cate, Jos G Maessen, Milan Milojevic, Bart Maesen, Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice, European Journal of Cardio-Thoracic Surgery, Volume 64, Issue 4, October 2023, ezad340, https://doi.org/10.1093/ejcts/ezad340

  4. Müther M, Schwindt W, Mesters RM, et al. Andexanet-Alfa-Associated Heparin Resistance in the Context of Hemorrhagic Stroke. Neurocrit Care. 2022;37(2):372-376. doi:10.1007/s12028-022-01573-5

  5. Watson CJ, Zettervall SL, Hall MM, Ganetsky M. Difficult Intraoperative Heparinization Following Andexanet Alfa Administration. Clin Pract Cases Emerg Med. 2019;3(4):390-394. Published 2019 Oct 14. doi:10.5811/cpcem.2019.9.43650

  6. [Peer-Reviewed, Web Publication] Whipple T,  Reuter Q. (2019, May 13). C-spine clearance with negative CT: Are we there yet? [NUEM Blog. Expert Commentary by Levine M]. Retrieved from http://www.nuemblog.com/blog/cspine-clearance-ct

  7. American College of Surgeons Committee on Trauma. Best Practice Guidelines: Spine Injury. Published online March 2022. https://www.facs.org/media/k45gikqv/spine_injury_guidelines.pdf

 

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