re blood thinning and internal bleeding

[ohyeahbaby]

i realize the ridiculousness of my q, especially as someone wrapping up m3, but please bear w/ me for just a sec.

let's say some dude overdoses on plavix, heparin, coumadin, or whatever...

yes, we won't stop bleeding or we won't stop bleeding easily if we get a cut, laceration, injury, etc... but what is up with this whole internal bleeding thing?

my question: if there are no internal injuries, why would someone have internal or cerebral bleeding?

yes, your blood is thin and you're at risk for bleeding, so no surgery for you... that, I get. But I've gotta be missing something.

if someone can explain that to me, i will be eternally grateful

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[pianoman511]

It is more related to the risk of internal bleeding. You have to acknowledge that if someone is on a blood thinner then they have some history of an MI, CVA, or some other condition. Most likely they have other comorbidities as well. The concern is that there is an existing abnormality in the GI tract (most common) or brain which can start bleeding if the ptt or pt is out of whack. I have seen inr >15 without significant bleeding. Just give some vitamin K and FFP and watch. Plavix is harder to reverse but if there's bleeding you can give platelets.

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[pianoman511]

For example, cerebral aneurysm or avm. Hemorrhoid, ulcer, diverticulum, etc.

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[Rendar5]

The honest real world answer is if there's bleeding, there's bleeding. if there's no bleeding then there's no bleeding. any tests you do for bleeding should be based on the person's symptoms and what you can look at. do you CT head someone just cause their coumadin's high? no, that's a waste of money, radiation, CT tech's time, etc. Do you do a rectal exam to check for hematochezia or melena? well that might be smart, minimal time, minimal money, minimal inconvenience. and often no symptoms until there's a lot of it. (and yes, have had people lie to me about hemathochezia when their INR came back 9.1)

everyday people can have microvascular bleeding and clotting from insignificant trauma or vascular defects. High INR just brings those things more in favor of the bleeding and further away from the clotting. spontaneous SAH is more likely with high INR, AVM bleeding from the gut is more likely with high INR.

 

[ohyeahbaby]

thank you both! That clarifies so much for me. I still can't believe you guys had dudes w/ INRs of 9 and 15. I didn't think that was possible.

Your explanations made perfect sense. Thanks again

 

[Siggy]

If you want to see some real lab value fun, there's always the Hall of Fame thread over in the EM forum.

http://forums.studentdoctor.net/showthread.php?t=115359

 

[Rendar5]

thank you both! That clarifies so much for me. I still can't believe you guys had dudes w/ INRs of 9 and 15. I didn't think that was possible.

Your explanations made perfect sense. Thanks again

INR goes as high as the lab is willing to test it. At some point, most labs will say INR>"arbitrary max", though that is extremely rare and you'll only really see that with fulminant liver failure. Most I ever saw was >20 for a tylenol OD. person was basically on life support with little hope of recovery without a liver transplant within a week (and even then to try and survive a surgery with an INR like that.