DILEMMAS IN DAY-TO-DAY CARE
IN THE NAME OF BLOOD
Pharmacology to the tune of anticoagulant reversal
By Brant Jaouen, MD; Ben Stone, FP-C; Jennifer Belcher Jones, RN, CCRN, CFRN, Jordan Kohler, NRP
& Ryan Hodnick, DO, NREMT-P, FAWM
Your EMS flight crew is dispatched by rotor to a remote hospital in the Great Basin Desert for a patient with
gastrointestinal (GI) bleeding. The patient
was brought in by her grandson. She was vomiting blood as well as suffering from
On arrival, you find an 80-year-
old female sitting up in a hospital bed, although she’s extremely
weak. She has a Glasgow coma scale
(GCS) of 15 and states she’s been
throwing up blood all day.
She appears pale but is in no
obvious distress. Her vital signs are
a heart rate of 100 with regular pulse;
blood pressure 60/35 mmHg; respiratory rate of 20; and SpO2 of 94%
with poor waveform on 2 L/min via
nasal cannula. The patient’s history is limited
to atrial fibrillation and hypertension.
Her nurse informs you that she’s received
80mg Protonix (pantoprazole) and a liter of
normal saline (NS). Given the patient’s active
GI bleed, her current blood pressure, and the
1. 5 hour-plus flight to the receiving facility, you decide it’s appropriate to request the
hospital’s only two units of packed red blood
You load the patient into the helo without
difficulty. As you begin transport, you find
yourselves facing a strong headwind. Your
pilot says that because of this you’ll have to
stop for fuel on the way to complete transport.
You and the crew put your heads together
and decide the best course of action is to set
down at your home hospital pad. This will
take you off course from your receiving hospital, but your home hospital has fuel and
additional blood products available.
The decision will add approximately 15
minutes to the already long transport, but
no other facilities can offer you what this one
has. You call ahead to have two units of fresh
frozen plasma (FFP) at the ready.
While on the way to get fuel and FFP, you
place the patient on nasal EtCO2 and obtain
an initial reading of 20 mmHg. You immediately begin transfusing the first unit of PRBCs.
The patient’s history of atrial fibrillation
gives you pause for thought and you look more
closely through the history and physical examination paperwork you received from her nurse.
Your concern is that this patient may be anti-coagulated—a measure to prevent clots from
forming in her less-than-rhythmic atria, but
also complicating her primary diagnosis of
a GI bleed.
The paperwork says she’s on warfarin. The
page with hospital labs tells you her international normalized ratio (INR) is 5.0 ( 1.0 is
normal; 2.0-3.0 is therapeutic for anticoagu-lated patients). You also come to find out that
the sending facility did, in fact, give the patient
vitamin K ( 10 mg IV), despite this not being
mentioned in the hand-off report you received.
You note that the patient’s blood pressure
begins to respond to the PRBCs as well as a
second liter of NS. Her systolic blood pressure
is now in the 80s and her EtCO2 is 28 mmHg.
The aircraft lands without incident to refuel
and two units of thawed FFP are
ushered out to the aircraft. After the
first unit of PRBCs has finished, you
immediately hang one of the units
The helicopter lifts. The patient
subsequently states to you that she
doesn’t feel well and begins projectile vomiting. Everything from the
monitor to the radio to the sun visor
on your helmet is painted in partially
You note that your patient has
become less responsive, at which
point airway protection now becomes paramount. Clicking up the visor, you locate and
reach for your only clean surface to work on:
a spare blanket. The setup for rapid sequence
intubation moves along smoothly as you pre-oxygenate, induce with ketamine, paralyze with
rocuronium and intubate.
The patient is placed onto the ventilator
before any notable desaturation occurs. Your
partner then inserts an orogastric tube and
attaches it to the suction unit, yielding a steady
and voluminous return of blood.
Continuing down the transfusion pathway
(and cleaning up where you can), you deliver
the remaining two units of blood products,
hoping to reverse your patient’s coagulopathy and perhaps replace some small amount
of what she’s lost. You add to that a dose of
IV calcium gluconate.
In spite of the staggering amount of blood
collecting in the suction canister and soaking
Everything, from the
monitor to the radio to
the sun visor on your
helmet is painted in
partially digested blood.