Dabigatran – bloody hell!

(first published on the underneaths of things)

I saw my first head-injured dabigatran patient the other day.

He was completely fine, neurologically intact, and had had no LOC, but had epistaxis and lip lacerations which had clotted fine, and an abrasion on his nose (He also had a Colles #).
I elected not to CT his brain, and there were no ED short stay beds so to “observe” him I had to admit him under the surgeons as a post trauma obs patient.

I was left with these questions:

- how worried do we need to be about ICH in these patients on dabigatran?
- should we scan ‘em, and should we admit them, or am I being cautious out of ignorance?
- are there lab tests to quantify how anticoagulated they are?
- if they are bleeding, can we fix it? (unlike Bob the builder, it would appear that “no we can’t!”)

It seems my ignorance is shared – noone knows what to do about these patients yet, but we will see more, they will get head bleeds, and we probably can’t stop the bleeding, as no reversal agents have been shown to be fully effective yet (although some have theoretical reversal effects). Some answers, such as we have so far, are in the links below:

http://emlitofnote.blogspot.com/2011/09/rivaroxaban-can-be-reversed-but-not.html
http://www.thepoisonreview.com/2011/09/11/dabigatran-toxicity-the-top-10-questions/
http://www.thepoisonreview.com/2011/09/11/3304/
http://www.thepoisonreview.com/2011/08/02/dabigatran-and-the-elderly/
http://www.thepoisonreview.com/2011/06/18/dabigatran-etexilate-a-new-challenge-for-emergency-physicians-and-toxicologists/
http://emcrit.org/wp-content/uploads/dabigatran-review.pdf
http://emcrit.org/wp-content/uploads/dabigatran-unc-guideline3.pdf

and a podcast from hqmeded (via emcrit.org):
http://emcrit.org/misc/bleeding-patients-on-dabigatran/

Apparently some GPs here are being “allowed” (encouraged?) to put 10 patients on their books on it.
This is being called a “trial” but it ain’t no RCT!!!
We will see more of it, that’s for sure!

About dreapadoir

Emergency Physician, author of http://underneathEM.com Emergency Medicine blog, photographer at http://www.dreapadoir.com
This entry was posted in Cases, Discussions and rants, Medical Musings. Bookmark the permalink.

5 Responses to Dabigatran – bloody hell!

  1. Pingback: Dabigatran – bloody hell revisited! | the underneaths of EM

  2. Leon Gussow says:

    It sounds like your GP’s have been induced to participate in a seeding trial, a particularly sordid —IMHO unethical — practice that is more marketing than research whose primary purpose is to increase prescribing of a specific medication. For more on seeding trials, see this paper from Archives of Internal Medicine: http://1.usa.gov/J2LMo4

  3. dreapadoir says:

    Thanks for the comment Leon. It is indeed a seeding trial. Another thing is, already despite the very specific indication for “non-valvular AF” there is creep, and primary care physicians are NOT adhering to this guide even for the ten patients they have been authorised to prescribe…

  4. Pingback: Dabigatran – a bloody mess? | the underneaths of EM

  5. Pingback: Funtabulously Frivolous Friday Five

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s