Blood thinners are putting ED geriatric patients at risk
Blood thinners are putting ED geriatric patients at risk
Change the way you triage and assess these patients
After a minor fall, an alert, neurologically responsive elderly woman was brought to an ED. She told triage nurses she was taking the anticoagulant warfarin. When the patient was brought to a treatment room, she was lethargic and less responsive.
"By the time she had her medical evaluation, she had deteriorated further and required endotracheal intubation," says Kathleen Emde, RN, MN, CEN, clinical services manager at Swedish Medical Center in Issaquah, WA. The woman was rushed for a computerized tomography (CT) scan, which revealed a large subarachnoid hemorrhage. She was given fresh-frozen plasma and other specific clotting factors, but she died a short time later in the intensive care unit.
You’ll be seeing an increasing number of elderly patients taking anticoagulants, says Emde. "Patients are kept in a hypocoagulable state to prevent complications from chronic atrial fibrillation, mechanical cardiac valves, or after major surgery to prevent deep venous thrombosis," she explains. This trend can have life-threatening implications in the ED, Emde says.
Patients taking anticoagulants will not form a normal clot as rapidly, so they may bleed more profusely and for a longer time than patients with normal coagulation, says Emde. "Other agents, such as the low molecular weight heparins, cause less effect on the ability to form a clot, but their presence still must be noted," she adds.
You can improve care of elderly patients on blood thinners by doing the following:
- Be sure waiting patients are reassessed.
Patients on anticoagulants need to have more than just "one-shot" triage, where only one evaluation takes place, says Emde. "This is a common method of triage, and patients often are not repeatedly evaluated in any sort of a systematic way while they are waiting," she says. "Triage needs to be seen as an ongoing process, rather than a one-time event to categorize the patient."
If there is any possibility a patient’s condition may be related to or worsened by their medication, you should perform serial re-evaluations of vital signs, circulation, motor function, and sensation, to ensure that the patient remains stable, advises Emde. For example, if a patient on anticoagulants arrives with a swollen, sprained ankle, that patient will not be able to stop bleeding into the tissues as readily as a patient with normal coagulation, she says. "So the initial treatment of applying ice, elevating the extremity, and applying a bandage should not be delayed," says Emde. "These measures would need to be initiated in triage."
- Consider giving patients a higher acuity.
Change your triage protocols to categorize any injured patient on anticoagulants as emergent, recommends Emde. "The purpose of this is to ensure that the patient is seen rapidly in case there is bleeding due to the drug, and to help get it controlled as rapidly as possible if it is present," she says. "Careful history-taking is a must."
- Modify procedures for patients taking anticoagulants.
If an arterial puncture is performed to draw a sample for arterial blood gas analysis, be aware that the puncture site is more likely to bleed and take longer to form a clot, says Emde. "Be aware of the presence of the drug and its effects, and hold pressure over the site for a longer period of time than would be required in other patients," she advises.
The same is true for patients who undergo cardiac catheterizations or other procedures that involve access through a large artery or vein, says Emde. These large vessels can bleed heavily into the surrounding tissues, which creates problems ranging from hematomas to compromised circulation to a limb to retroperitoneal hemorrhage, she explains.
"Again, prolonged direct pressure is usually enough to control these sites, but the nurse must be vigilant and check and recheck the sites often to be sure that hemostasis is being maintained," says Emde.
- Try not to phlebotomize the hand if possible.
The elderly have less subcutaneous fat and elasticity in the veins, says Linda Whitt, RN, BSN, CEN, ED nurse at Bon Secours DePaul Medical Center in Norfolk, VA. "Therefore, if a punctured vein keeps bleeding after a stick because the puncture doesn’t readily seal up, and the blood is thinned, then the hand will get a huge black ecchymosis as the leaky blood spreads under the skin," she says. "Not only is this painful, but it looks barbaric!"
- Be ready to reverse the effects of warfarin.
Patients may need to be given fresh-frozen plasma or other coagulation factors such as vitamin K injections to help restore clotting ability, says Emde. However, injections of vitamin K will not have an immediate effect, and you probably will need to use fresh-frozen plasma or other factors to restore a more normal clotting ability before the patient goes to surgery or has an invasive procedure such as lumbar puncture performed, she explains.
Since admitted patients often are held for hours in the ED, fresh-frozen plasma is being given more often in the ED, says Emde. "It is especially likely in patients who need to be able to clot sooner rather than later, such as patients who are actively bleeding or who are going to the OR soon," she says.
Sources
For more information on elderly patients taking anticoagulants, contact:
- Kathleen Emde, RN, MN, CEN, Clinical Services Manager, Swedish Medical Center-Issaquah Campus, 2005 N.W. Sammamish Road, Issaquah, WA 98027. Telephone: (425) 394-1646. Fax: (425) 396-1647. E-mail: [email protected].
- Linda Whitt, RN, BSN, CEN, Staff Nurse, Emergency Department, Bon Secours DePaul Medical Center, 150 Kingsley Lane, Norfolk, VA 23505. Telephone: (757) 889-5112. E-mail: [email protected].
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