Thrombotic thrombocytopenic purpura: An unusual presentation with intracranial bleed

Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening thrombotic microangiopathy characterized by microangiopathic hemolytic anemia, severe thrombocytopenia, and organ ischemia linked to disseminated microvascular platelet-rich thrombi. We present the case of a 44-year-old lady who presented with severe thrombocytopenia and anemia that did not respond to repeated transfusions and steroids. Non-contrast computed tomography scan of the brain revealed an intracranial bleed. Schistocytes were seen on the peripheral blood smear. A provisional diagnosis of TTP was made. Plasmapheresis could not be done due to her deteriorating hemodynamic status. She succumbed to her illness in spite of the best possible efforts. This case highlights the need for keeping a high index of suspicion for TTP as early diagnosis and prompt initiation of plasmapheresis are crucial for preventing death.

Factor XIII Deficiency and Intracranial Bleed: Surgical Management and Prophylaxis with Cryoprecipitate

Factor XIII (FXIII) deficiency is a rare bleeding disorder with affected patients having high propensity for intracranial hemorrhage. A 12-year-old girl presented with severe headache, limb weakness, and rapidly worsening sensorium over 4 days. Magnetic resonance imaging of the brain and computed tomography (CT) of the head showed intraparenchymal bleed. Patient had normal coagulation profile and abnormal FXIII level. The perioperative management included cryoprecipitate transfusion to bring the FXIII value to 74%. She underwent craniotomy and evacuation of the hematoma. Postoperatively, she received prophylaxis against rebleed with cryoprecipitate. In the absence of FXIII concentrate, correction of FXIII deficiency is possible with cryoprecipitate in emergent situations.

Upright (45°) Versus Supine Position for Intubation in Intracranial Bleed Patients

Objective: To find out the effective method of endotracheal intubation among patients of intracranial bleed. Methods: A quasi experimental research was performed at emergency department of Ziauddin University Hospital Karachi. 236 intracranial bleed patients were selected by consecutive sampling, half of them were intubated at upright position (45°) and remaining half at supine position. Patients of musculoskeletal deformities, ischemic stroke and previously intubated were excluded. Success or failure of endotracheal tube was confirmed by measuring oxygen saturation and audible breath sounds on chest. Results: Success rate of endotracheal placement (p-value <0.001) was high in upright position 115 (97.5%) as compared to supine position 90 (76.3%). Similarly, endotracheal tube placement attempts (p-value <0.001) and completion time (p-value <0.001) was low in upright position 1.1 ± 0.4 and 62.9 ± 24.9 sec as compared to supine position 1.5 ± 0.9 and 90.2 ± 67.9 sec. Conclusion: Endotracheal intubation of intracranial bleed patient at upright position is more successful, effective, less painful in terms of number of attempts and less time consuming as compared to supine position.

Early Coagulopathy in Pediatric Traumatic Brain Injury: A Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) Retrospective Study

BACKGROUND Although early coagulopathy increases mortality in adults with traumatic brain injury (TBI), less is known about pediatric TBI. OBJECTIVE To describe the prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet levels of children with moderate to severe TBI to identify predictors of early coagulopathy and study the association with clinical outcomes. METHODS Using the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) TBI retrospective cohort, we identified patients &lt;16 yr old with a Glasgow Coma Scale (GCS) ≤13. We compared PT, APTT, platelets, and outcomes between children with isolated TBI and multiple trauma with TBI. We performed logistic regressions to identify predictors of early coagulopathy and study the association with mortality and poor functional outcomes. RESULTS Among 370 children analyzed, 53/370 (14.3%) died and 127/370 (34.3%) had poor functional outcomes. PT was commonly deranged in both isolated TBI (53/173, 30.6%) and multiple trauma (101/197, 51.3%). Predictors for early coagulopathy were young age (adjusted odds ratio [aOR] 0.94, 95% CI 0.88-0.99, P = .023), GCS &lt; 8 (aOR 1.96, 95% CI 1.26-3.06, P = .003), and presence of multiple trauma (aOR 2.21, 95% confidence interval [CI] 1.37-3.60, P = .001). After adjusting for age, gender, GCS, multiple traumas, and presence of intracranial bleed, children with early coagulopathy were more likely to die (aOR 7.56, 95% CI 3.04-23.06, P &lt; .001) and have poor functional outcomes (aOR 2.16, 95% CI 1.26-3.76, P = .006). CONCLUSION Early coagulopathy is common and independently associated with death and poor functional outcomes among children with TBI.

SNAKE BITE PRESENTING AS INTRACRANIAL BLEED WITH NORMAL COAGULATION PARAMETERS

Snakebite being commonly encountered emergency in our country and most dreaded one too. It has been estimated that as many as 2.8 million people are bitten by snakes, and 45 900 people die from snakebite every year in India1. The most common coagulopathy associated with snake-bite envenoming is Venom Induced Consumptive Coagulopathy. Venom contain enzymes like proteases, phospholipase A2, hyaluronidase and arginine ester hydrolase. Phospholipase A2 is the factor responsible for hemolysis secondary to the esterlytic effect on the red cell membranes The hyaluronidase causes spread of the venom in the subcutaneous tissue by disrupting mucopolysaccharides. In majority of cases there is disruption in coagulation profile causing increase in PT, INR, aPTT, thrombocytopenia and increase in FDP, which suggests DIC as the probable cause for intracerebral hemorrhage . But always it is not true there are some cases in which there is hemorrhagic risk without alteration in coagulation profile. All my 3 cases present to us with normal coagulation profile , One 26 year old male present within one hour of snake bite and died within 3 days of the bite, while other two presented lately that is 2and 6 day of the snake bite ,of which both survived and had no residual focal deficit at time of discharge. This delayed clinical, laboratory manifestation of vasculotoxic snake due to the delayed seepage of venom from deeper reservoirs in the bite site or due to disassembly of the antigen-antibody complex with reinstitution of circulating unbound venom constituents. Intracranial hemorrhages are poorly understood in case of snake bite and can occur later complication also even after treatment with ASV. Still use of FFP is not advocated in much studies, there is immense need to investigate this area. Use of ASV and FFP without increased WBCT to avoid later complication is to be studied.

Abstract 15084: A Retrospective Analysis of Atrial Fibrillation Patients Aged 80 Years and Older Prescribed a Low-dose Non-vitamin K Antagonist Anticoagulant

Background: The very elderly and those receiving low doses of the direct-acting oral anticoagulants (DOACs) were underrepresented in trials leading to the approval of Apixaban 2.5 mgs BID (A), Rivaroxaban 15mgs daily (R) and Edoxaban 30 mgs daily (E). Approval of dabigatran 75mgs BID (D) was based entirely on pharmacokinetic studies. Methods: Retrospective analysis of the electronic medical record of a multi-disciplinary practice of 396,064 patients between 1/1/11 (when first DOAC available) and 5/31/17. Results: 9,446 patients had Atrial Fibrillation (AF), with 2,660 prescribed a DOAC and 846 at the low dose with 514 ≥ 80 yrs (range 80 – 98) with a mean CHA 2 DS 2 -VASc score of 4.5, which did not differ between patients prescribed D, R or A (p = 0.66 by ANOVA). Fifty-three patients received D, first used on 2/26/11, 223 R, first used on 12/15/11, and 236 A, first used on 6/19/12, and one patient received E. Among 28 baseline variables there were no clinically relevant differences among D, R, and A. All outcomes were reported as time to first event. All-cause mortality, n = 5 (5.5%/yr) for D, n =15 (4.2%) for R, and n = 23 (9.5%) for A, p = 0.031 by log rank test (with A > R by pairwise log-rank, p = 0.013). Major bleeding n = 13 (14.3%/yr) for D, n = 50 (14.1%) for R, and n = 22 (9.1%) for A, p = 0.048 by log rank test (with A < R, p = 0.017). Intracranial bleeding n = 2 (2.2%/yr) for D, n = 6 (1.7%) for R, and n = 2 (0.8%) for A, p = 0.53. There were 7 ischemic strokes or systemic embolic events (SSE) in total (1.1%/yr): D, R, and A (p = 0.94). Comparisons involving D may be underpowered. 245 patients (47.7%) remained on their prescribed drug without an event for the observation period (p = 0.55). Conclusion: D, R and A were well tolerated in patients ≥ 80 yrs, with low SSE and intracranial bleed rates. Major bleeds were the most frequent outcome, lowest in patients prescribed A. A had a higher all-cause mortality.

Dengue-Associated Posterior Reversible Encephalopathy Syndrome

Dengue fever has been associated with a myriad of complications, due to widespread inflammation in the various afflicted organs. Central nervous system (CNS) complications include encephalitis, encephalopathy, intracranial bleed, and spinal and cranial nerve involvement with varied outcomes. We report a case of an adolescent girl who presented with dengue fever and significant hypotension requiring intravenous fluids and vasopressors, and developed seizures on the third day of admission. Magnetic resonance imaging (MRI) of brain showed features suggestive of posterior reversible encephalopathy syndrome. She was managed conservatively with antiepileptics. She showed complete clinical recovery over the next 3 days and remained normal with seizure freedom at a recent follow-up after tapering antiepileptics.

Outcome of neonatal thrombocytopenia in tertiary care NICU

Thrombocytopenia is one of the commonest haematological disorders in the neonatal period, affecting up to a third of those admitted to neonatal intensive care units. It is well recognized that many fetomaternal and neonatal conditions are associated with thrombocytopenia. The majority of episodes of neonatal thrombocytopenia are relatively mild, self-limiting and of short duration but it may cause severe morbidity & mortality due to severe complication like IVH. Methods & material: 140 Newborn admitted in tertiary care NICU were selected to find out outcome and etiology of neonatal thrombocytopenia. Detail maternal history and neonatal physical examination done and Neonates were followed for outcome, relevant investigation done according to cases. Result: Out of 140 neonates 63 neonates had thrombocytopenia (45%).42.8% neonates were premature out of which 63.3% had thrombocytopenia. Other neonatal risk factor for thrombocytopenia are sepsis 38 (74.5%), SGA/IUGR 28(80%) and NEC 9(100%). Maternal risk factor for thrombocytopenia are eclampsia81.8% and infection during pregnancy 72.72%. 95.5 % of all study population were discharged.4.5 % cases of whole study population didn’t survive. 4.54% of mild, 9.09% of moderate and 60 % of severe thrombocytopenic babies didn’t survive. Conclusion: Bleeding manifestations i.e. mucosal, cutaneous and intracranial bleed were significantly associated with severe thrombocytopenia. 60% of mortality was found in severe thrombocytopenic group. Thus, severe thrombocytopenia was found to be a predictor of poor outcome in sick neonates of NICU.