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Blood transfusion
0%
0/65
No treatment changes needed
12%
8/65
Platelet transfusion
3%
2/65
Start warfarin
57%
37/65
Stop heparin
26%
17/65
Select Answer to see Preferred Response
This patient is presenting with a pulmonary embolism (chest pain, hypoxia, tachycardia, and a CTA with a thrombus in the pulmonary vasculature) and was treated with heparin. He experienced a profound drop in platelets 6 days later which is concerning for heparin-induced thrombocytopenia (HIT) type II which warrants immediately stopping the heparin. HIT type II is an antibody-mediated disorder of coagulation caused by exposure to heparin resulting in significant risk of thromboembolic complications and death. The diagnosis is mainly clinical but can be confirmed with an ELISA or functional assay against PF4 autoantibodies. Patients will present with a drop in their platelet count and possible thrombosis. If HIT type II is suspected, the patient should immediately have heparin discontinued and be started on an alternative anticoagulant such as a direct thrombin inhibitor. Incorrect Answers: Answer 1: Blood transfusion would not be needed as this patient is not rapidly losing blood (his anemia is likely from his malignancy) and his hemoglobin is > 7.0 g/dL. Answer 2: No treatment changes needed is incorrect as HIT warrants immediate cessation of heparin and administration of a direct thrombin inhibitor. Answer 3: Platelet transfusion may actually worsen HIT. It would be indicated, in general, when there is a platelet count < 10,000 or < 50,000 in the setting of bleeding. Answer 4: Start warfarin is incorrect as heparin must promptly be stopped in HIT type II. Typically, heparin is bridged to warfarin until the INR is therapeutic. Bullet Summary: Heparin-induced thrombocytopenia type II should be treated with cessation of heparin and given a direct thrombin inhibitor instead.
4.9
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