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Packed red blood cells transfusion
2%
3/121
Dimercaptosuccinic acid (DMSA)
7%
9/121
Vitamin K and fresh frozen plasma
70%
85/121
Penicillamine
Protamine sulfate
5%
6/121
Select Answer to see Preferred Response
This boy has an elevated INR and epistaxis, likely due to rodenticide toxicity, which is similar to coumadin in its effects. The appropriate treatment involves administration of vitamin K and fresh frozen plasma. Anticoagulant rodenticides act in a mechanism similar to coumadin. These compounds inhibit vitamin K epoxide reductase, thereby preventing gamma-carboxylation of clotting factors. The activation of clotting factors occurs primarily in the liver. The factors affected include factors II, VII, IX, X, protein C, and protein S. Existing clotting factors are not affected. This boy's extremely elevated INR with approximately normal PTT suggests that he was in contact with a substance that affects the extrinsic coagulation cascade, such as warfarin. Horton and Bushwick review the effects of vitamin K antagonism. Activation of coagulation factors II, VII, IX, and X requires vitamin K as a cofactor. By blocking the ability of vitamin K epoxide reductase to gamma-carboxylate inactive factors, the extrinsic coagulation pathway is hindered. The authors present an algorithm for the management of elevated INR. If a patient is bleeding and has a significant elevation of their INR, it is appropriate to give vitamin K to aid in the production of future clotting factors, as well as to give fresh frozen plasma, which contains activated factors for immediate use. Watt et al. discuss rodenticides. Warfarin was developed as a rodent poison in the 1940s. However, rodents subsequently became resistant to the drug, and thus stronger formulations were devised. Modern anticoagulant rodenticides include brodifacoum and bromadiolone. These compounds act via a similar mechanism but have a longer duration of action and are more potent. Incorrect Answers: Answer 1: This patient's bleeding does not appear significant enough yet to warrant transfusion. Moreover, his anticoagulation needs to be reversed immediately. Answers 2, 4: Dimercaptosuccinic acid and penicillamine are chelating agents that may be used for certain metal poisonings. Answer 5: Protamine sulfate is used for reversal of heparin overdose.
3.5
(4)
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