Question

A 60 year old woman with chronic RA has been treated with NSAIDS, undergoes elective left knee replacement. Develops evidence of DVT post-op, duplex exam confirms DVT in left femoral vein. She receives IV heparin bolus of 5,000U followed by heparin drip infusion of 1,000 U/hr. which maintains her PTT at 2x control. On the third day of heparin tx, she vomits 100mL of bright red blood but otherwise feels fine and has stable vitals. How do you evaluate and manage this patient?

Answer 1

The patient's vomiting of bright red blood while on heparin therapy for DVT suggests gastrointestinal bleeding, likely related to anticoagulation. Management should focus on stopping the heparin, assessing coagulation status, reversing anticoagulation if necessary, identifying and treating the bleeding source. Adjusting future anticoagulation treatment will also be important.

Step-by-step explanation:

A 60 year old woman with chronic RA who has undergone a knee replacement develops a DVT post-operatively and is treated with heparin. She then vomits 100mL of bright red blood on the third day of treatment. The immediate priority is to ensure hemodynamic stability, which seems to be the case here as her vitals are stable. Nonetheless, one must consider gastrointestinal bleeding as a possible side effect of anticoagulation therapy. The management would include stopping the heparin infusion, evaluating her coagulation status (PTT, INR, platelet count), and assessing for the need of reversal agents for heparin. Additionally, an urgent gastroenterology consultation for possible endoscopy to locate and treat the source of bleeding is necessary. Supportive care with intravenous fluids or blood transfusion may be required depending on her clinical status and laboratory results. Subsequent anticoagulation strategies should be considered with caution, taking into account the risk of recurrent bleeding.