Subdural Hemorrhage and GI Bleed due to Coumadin Overuse
Patient Presentation:
D.A., a 61 year old male, was brought to the ER at an OSH by EMS, responding to a call from an assisted living facility, due to the patient’s change in mental status. At the OSH, the patient became obtunded and was intubated for airway protection. A head CT without contrast was done and a diagnosis of an acute right subdural hemorrhage with presence of a chronic head hemorrhage (acute on chronic) was made. His INR was 9.0. The patient received 4 units of platelets and was flown to a local hospital for further treatment/stabilization. D.A. has an extensive pmhx including: obesity, COPD, HTN, CVA, PVD, MI, A-fib (currently on Coumadin®), Gout, DVT, and left BKA.
Differential List:
Spontaneous subdural hemorrhage from unmonitored Coumadin® tx, DIC, Hypoglycemia
Diagnosis:
When D.A. arrived to the Neuro ICU, there was copious amounts of melena stools coming from the patient. Abnormal labs were as follows:
INR: 2.6 (0.8 - 1.2), PT: 26.8 sec (11.8 - 14.5)
Glucose: 147 mg/dL (65 - 120)
BUN: 94 mg/dL (9 - 20), Creatinine: 8.92 mg/dL (0.66 - 1.50)
Platelet: 139 k/uL (145 - 400)
RBC: 2.50 million/uL (4.20 - 5.50), Hgb/Hct: 6.6 gm/dL (12.5 - 16.5) / 22.9% (37.5- 49.5), + Fecal Occult Blood Test (Blood present in the stool)
A portable chest x-ray was done to confirm correct placement of the endotracheal tube and to evaluate chest infiltrates. The x-ray showed enlarged heart size (cardiomegaly), bilateral atelectasis and pleural fluid. No presence of a pneumothorax was noted. A 2-D echo showed worsening left ventricular function and a slightly higher pulmonary artery systolic pressure (compared to an echo done 4 months earlier.) The ejection fraction was found to be <15%. The right ventricular systolic function was severely reduced. Right ventricular systolic pressure was 65 - 70 mmHg. Moderate to severe pulmonary hypertension was evident. The neurosurgery team was not going to proceed with surgery due to the alarming bleeding and abnormal labs. The GI team was consulted and they too did not want to proceed with an endoscopy on D.A. for the same reasons.
Treatment:
D.A. was given packed RBC’s and platelets, and phytomenadione IV (Vitamin K) to reverse Coumadin’s® affects. Coags and Hgb/Hct were checked q6 hours. A Protonix® gtt (proton-pump inhibitor) was also started for treatment of the GI bleed. His orogastric tube was placed on intermittent low wall suction with large amounts of dark output suctioned out. He was not placed on any antihypertensive medications due to his state of losing volume. He was started on Cardizem® (calcium channel blocker) 0.25mg/kg IV q8 hours to control his heart rate. On hospitalization day 2, the patient had seizure activity (evident by bilateral eye deviation to his left, facial and tongue twitching, and right arm jerking). The patient was given 2 mg Ativan ® IV q 4 hours prn for seizures. He was also started on Keppra® 500 mg IV TID for seizure prophylaxis.
Outcome:
A week into his hospitalization, D.A. was obtunded, not able to follow simple commands, and was unable to be weaned from full ventilation support. He was transferred from the Neuro ICU to the MICU since the neurosurgery team had no plans to operate due to his numerous co-morbidities. After speaking with the MICU physicians, his family decided to make D.A. DNR status. After his GI bleed was resolved from the reversal of Coumadin® and seizures were no longer witnessed, the patient received a bedside tracheotomy and PEG. He was then transferred to a long-term ventilator support facility.