New anticoagulants are revamping care in EDs
New anticoagulants are revamping care in EDs
Nurses moving away from heparin
New anticoagulants, including low molecular weight heparins (LMWHs) and nonheparin compounds, are changing the way ED nurses care for patients with acute thrombotic disorders.1
"I think it's very clear that we're moving away from heparin," says Robert D. Powers, MD, MPH, faculty in the Department of Emergency Medicine at the University of Virginia School of Medicine in Charlottesville.
"It turns out that heparin isn't that great a drug, even though we're all very familiar with it," he says. "We are moving very quickly to heparin-related compounds or compounds that work in a different way and are totally unrelated to heparin."
Many of the new anticoagulants are easier to administer since most don't require the loading dose and drips that heparin does, adds Powers.
ED nurses at University of Virginia Health System in Charlottesville are using enoxaparin much more frequently for treatment of acute myocardial infarctions (AMIs) and coronary syndromes, says Ryan Meszaros, RN, an emergency nurse at the hospital. Previously, for AMI patients, the decision was made to give thrombolytics or send patients to the cardiac catheterization lab. A nitroglycerin drip and heparin bolus was given, followed by a heparin drip.
Now, most patients are started on heparin, admitted and sent home on enoxaparin if the prolonged need for anticoagulation is needed, he says.
This change means ED nurses administer a single drug, instead of giving the heparin bolus and using the infusion bag, tubing, and pump, Meszaros explains. "We still must know the weight of the patient, but at 1 mg/kg dosing in a prefilled syringe, there is little room for medication calculation error." With heparin, nurses needed to calculate the bolus and drip rate as well as program the pump correctly, Meszaros says. "These calculations and drawing up of the medications can be difficult in calm situations, never mind in high stress times as with an AMI."
The previous protocol with heparin involved nurses hanging the intravenous dose on a pump, doing lab draws, and changing flow rates as needed, whereas the new drugs require only timed injections and blood draws, says Ken Lanphear, RN, ED nurse at Borgess Medical Center in Kalamazoo, MI. "The newer drugs do make life simpler as we do not have to run as many drips as we once did," he says. "The drugs are easier and quicker to use."
No antidotes, but fewer allergies
One concern is that not all the drugs have antidotes and may require fresh frozen plasma or other modalities to reverse their effects. "Protamine can reverse heparin fairly quickly," says Powers. "There are not simple antidotes for all of the new compounds."
A common misconception is that LMWHs can be reversed with protamine when in fact it has only a partial effect, he says. "So once you give it, you really are committing to the person being anticoagulated for some time."
Another misconception is that vitamin K acutely helps patients who were given too much of the oral anticoagulant warfarin, when in fact it only helps with the synthesis of the clotting factors and takes many hours or even days, says Powers. "So again, you have to go to fresh frozen plasma," he adds.
You need to ask the right questions, because patients won't always understand the side effects of their medications, says Meszaros. If the patient is symptomatic with hypotension, altered mental status, shortness of breath, or feeling dizzy, ED nurses infuse normal saline, obtain vital signs and an electrocardiogram, and give fresh frozen plasma or vitamin K. "However, Lovenox really has no antidote and receives the same treatment as with Coumadin or heparin overadministration," he says. "The main intervention is supportive care based on the symptoms present."
Heparin is prone to causing allergic reactions, adds Powers. "Thankfully, heparin-induced thrombocytopenia doesn't happen that often, but it is potentially catastrophic," he says. "It is much less common with LMWHs than with heparin, and it doesn't occur at all with non-heparin compounds."
LWMHs are changing the way some patients with suspected deep venous thrombosis (DVT) are cared for in the ED after hours when definitive diagnostic testing is unavailable, says Powers. "It's perfectly safe and acceptable now to give some of them a shot of enoxaparin, send them home, and bring them back the next day for imaging," he says. With heparin, that response wasn't possible because it wore off too quickly, whereas enoxaparin lasts for 12 hours, Powers says. "Some DVT patients can even be managed at home, and the fewer people we have to admit, the fewer will have to wait in the ED for beds," he says.
Reference
- Kuntz JG, Cheesman JD, Powers RD. Acute thrombotic disorders. Am J Emerg Med2006; 24:460-467.
Sources
For more information about anticoagulants for acute thrombotic disorders, contact:
- Ken Lanphear, RN, BSN, Emergency Department, Borgess Medical Center, 1521 Gull Road, Kalamazoo, MI 49048. Telephone: (269) 383-8232. E-mail: [email protected].
- Ryan Meszaros, RN, Emergency Department, University of Virginia Health System, 1215 Lee St., Charlottesville, VA 22908. Telephone: (434) 924-2231. Fax: (434) 982-1001. E-mail: [email protected].
- Robert D. Powers, MD, Department of Emergency Medicine, University of Virginia School of Medicine, P.O. Box 800699, Charlottesville, VA 22908. Telephone: (434) 924-8488. E-mail: [email protected].
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