About Moises Gallegos, MD MPH

Editor, ALiEM
Section Editor, ALiEM Medical Student Home Page
Clerkship Director
Clinical Assistant Professor of Emergency Medicine
Stanford University School of Medicine

How I Educate Series: Moises Gallegos, MD

This week’s How I Educate post features Dr. Moises Gallegos, the Clerkship Director at Stanford University. Dr. Gallegos spends approximately 75% of his shifts with learners which include emergency medicine residents, off-service residents, medical students, and physician assistant students. He describes his practice environment as an academic Emergency Department at a medical research institution that serves as a Level 1 Trauma facility. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Collaborative, Safe, Growth-oriented

What delivery methods do use when teaching on shift?

My teaching approaches revolve around the concepts of microlearning and dual-coding. For example, I utilize a shared google doc where as a team we compile learning summaries along with curated links that are meant to be reviewed at a later time, whiteboards for just-in-time learning through reinforcement and clarification of topics, and often post-its or notecards to highlight the highest yield information for relevant topics.

What learning theory best describes your approach to teaching?

As mentioned above, I try to align my teaching to concepts of microlearning and dual-coding theories. With ideas of digestible teaching moments and creative design for knowledge retention, I also try to find balance with cognitive load theory in recognizing when it’s OK to introduce teaching vs. when it’s necessary to help offload tasks and clinical duties.

What is one thing (if nothing else) that you hope to instill in those you teach?

I try and convey to learners and trainees that the identification of a knowledge or skill gap is an opportunity for growth and should not be seen only negatively as a shortcoming. Training years are meant to be protected time for recognizing what to prioritize learning and where to focus attention. I would much rather you let me know early about a knowledge or skill gap so that we can work together to find the answer or deliberately practice maneuvers.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

The flow of on-shift teaching is dynamic. I like to think about teaching as being a series of bite-sized pieces, able to stand independently but part of a bigger whole. For example, the topic of COPD can be represented by a sandwich that has many ingredients. I may take a bite out of the COPD sandwich and teach on the concept of NIPPV, but then have to task-switch to something else and put the sandwich down. I may be able to come back later and take another bite, maybe on the role of steroids and antibiotics, or I may not. Doesn’t take away from the prior teaching on NIPPV which the learner has already walked away with.

Similarly, you may start a shift and be able to directly address/cover a few different things. Then it gets busy and it’s no longer possible to sit and cover more information rather you spend more time supporting the trainee through the process and tasks of patient care.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

I tend to skim the notes on shift for glaring deficits or necessary clarification, but don’t review the note fully until after the shift is done. I also let the resident know that I would encourage them to get the majority of the note done in real-time, but that they are able to edit after shift before I close it out. During the shift, I may provide general suggestions to improve, but often I find myself following up with an email in which I am able to provide directed feedback and corrective examples for what was written.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Even at an academic center, patient care needs can make dedicated teaching difficult. I think the secret is finding balance. Don’t pull the trainee away from tasks for too long to teach or the moment will be soured, but also don’t allow them to work an entire shift without feeling that attention was focused on their growth and learning. I try and evaluate if the moment, the trainee, and the timing are right. If it’s not, then I keep notes about what I want to communicate to or with the trainee and accept that I may not be able to do teaching in the moment, but at a later time, I want to draw their attention to a topic or a suggestion for improvement.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

Expectation setting is helpful in this case. At the beginning of shifts, I like to directly ask the resident what role they would like me to take that they find most helpful. Would they prefer that I represent a sounding board for ideas, allowing them to think out loud per se prior to my giving them suggestions? Do they want me to hover and follow along peripherally with the understanding that I will jump in for critical correction? Or do they want me to be a safety net available for them at every step? The point is to understand what level of autonomy they are comfortable with, and therefore will benefit from.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

If there are learners from various levels, I like to start the shift with a collective understanding of expectations for each role. This allows me to clarify with the senior what their role is in teaching the juniors. From there, I may ask each learner if they have specific goals for the shift. I eventually create objectives that I would like to meet with each learner as their case load develops and I am able to assess where they are at.

Do you typically see patients before or after they are presented to you?

This depends on the moment. If the flow of the department is being managed well by the residents and I know that they will be seeing patients in a timely manner, I tend to review the chart and look at vitals as well as nursing notes while waiting for a formal presentation. If there are multiple new patients or some more critically ill patients, I will try to sneak in to see patients briefly and get a gestalt of their state before the residents see the patient. If there is nothing too critical to be done, I will still allow the residents some time to place orders and initiate management on their terms.

How do you boost morale amongst learners on shift?

I’ve gotten in the habit of taking notes on learners. On my phone, I try to jot down what music they try to listen to, whether they had a vacation recently or upcoming, etc so that I can initiate some nonclinical conversation while we work. It’s not always possible, but I might bring snacks or buy coffee. Often, I offer to take the phone and will try to see a new patient on my own while sending them to get coffee or food with the understanding that they don’t have to rush back. If tasks start to build up, I make sure to ask the residents which of those items I can take off their list so it’s understood who is doing what, and we can work towards a disposition together.

How do you provide learners feedback?

Ideally, I like to provide in-person feedback prior to then submitting a formal written evaluation. This ensures that they are not caught off guard, that they understand what is meant, and even provides an opportunity for them to provide context that may allow me to understand more about their performance that shift (recently ill, tired, got called in, etc). I tend to follow up this in-person feedback with a summary email when it had to do with a more in-depth conversation. With any feedback in-person though, I check in and ask “is now an OK time for some feedback?” This could be at the end of the shift as a summative, but if it happens to be more in real-time during a case I make sure to ask if it’s an OK time and also try to be specific: ‘I had some feedback on [insert specific thing]- is now OK to talk or should we do it later?”

What tips would you give a resident or student to excel on their shift?

Every patient encounter has an opportunity for learning. Growth comes when we purposeful identify where we could improve, and take steps towards doing that. There is learning to be had with going through the stresses of carrying many patients at once, handling those difficult conversations, finding out the best ways to do this and that, but recognizing that we are there as a team. We can do that learning together. Cognitive overload can be detrimental if not done in the right way.

Are there any resources you use regularly with learners to educate during a shift?

In the shared Google document, I tend to highlight some of the FOAMEd blogs that are more “to the point” and that I feel are not overwhelmingly in-depth (First10EM, EM@3AM from emDocs, CoreEM, etc).

What are your three favorite topics to teach during a shift?

If I wouldn’t have become an EM doc, I would have likely become a cardiologist. I enjoy talking about ECGs and dysrhythmias. Also, I enjoy talking about Airway/intubation preparation and troubleshooting.

What techniques do you employ when teaching on shift?

As mentioned above- whiteboard teaching, visual demonstrations, quick reviews, Socratic method of questions to assess learner level, and supported experiential learning.

What is your favorite book or article on teaching?

Books: Make it Stick-Roediger, McDaniel, Brown; The Courage to Teach- Palmer.

Article: Not Another Boring Lecture: Engaging Learners with Active Learning Techniques– Wolff et al.

Who are three other educators you’d like to answer these questions?

Ashley Rider and Leonardo Aliaga

Read other How I Educate posts for more tips on how to approach on-shift teaching.

By Moises Gallegos, MD MPH|2022-07-29T09:14:52-07:00Aug 17, 2022|How I Educate, Medical Education|

ALiEM Stands in Solidarity with Our Asian American and Pacific Islander (AAPI) Community

We at ALiEM wholeheartedly condemn the xenophobia, intolerance, and hate crimes directed towards Asians and the Asian American and Pacific Islander (AAPI) communities. Recent events spurred by the COVID-19 pandemic are hurtful, “othering,” and simply unacceptable.

Anti-Asian hate crimes across the country since the onset of the COVID-19 pandemic have increased 833% in 2020, compared to 2019, in cities across the United States [1]. This heart-breaking trend of violent assaults against individuals in the AAPI community is misguided and counter to the healing and building that our country direly needs as a result of the global pandemic.

Last week’s shootings in the Atlanta area that claimed the lives of eight people, including six Asian women, have had devastating effects on the AAPI community. For some, it has sparked recollections of previous incidences of bias they themselves have experienced. For others, it has been a call to action, on how to be better advocates and allies for all people of color.

We stand in solidarity with our AAPI communities and allies. These hate crimes continue to highlight the ongoing and longstanding structural anti-Asian and anti-immigrant racism in our country. Each of us has the capacity to show kindness, compassion, and respect for one another. Each of us has the capacity to stand up for those tormented and racialized. Let us work together to overcome the hate and bigotry that plague our nation.

What can you do to be an ally?

References

VOA News: Hate Crimes Targeting Asian Americans Spiked by 150% in Major US Cities

By Moises Gallegos, MD MPH|2021-03-28T10:19:46-07:00Mar 26, 2021|Life, Public Health|

ACEP E-QUAL Podcast: Buprenorphine After Opiate Overdose

The opiate epidemic continues to be a frontline issue for healthcare systems across the country. The American College of Physicians (ACEP) Emergency Quality (E-QUAL) Network, through its Opioid Initiative Goal, strives to promote the implementation of alternatives to opioids, improved opioid prescribing safety, and adoption of harm reduction strategies such as naloxone prescribing and medication-assisted therapies (MAT). In a two-part series of the ACEP E-QUAL Network Podcast, host Dr. Jason Woods discussed buprenorphine initiation after an opioid overdose in the Emergency Department (ED) with Dr. Andrew Herring, Associate Director of Research and Medical Director of the Substance Use Disorder Treatment Program at Highland Hospital in Alameda County California. Below are show notes reviewing basic concepts of buprenorphine and recommendations for dosing in the ED.

Where do I get a DEA X-waiver?

With the rising interest in MAT, several programs are beginning to provide increased access to training and certification. ACEP will be working in partnership with the Providers Clinical Support System to provide online training. Dates can be found here.

What do I need to know about buprenorphine?

Buprenorphine is a potent opioid that is used to treat pain and for MAT in opiate use disorder (OUD).

Buprenorphine is slow to bind opiate receptors but has a high enough affinity that it can outcompete other opiates like fentanyl and methadone, and can even outcompete naloxone.

Buprenorphine has a ceiling effect in analgesia and respiratory depression that makes cumulative and higher initial dosing relatively safe.

Who is buprenorphine right for?

Buprenorphine as MAT for OUD is intended for clear stories of an opiate overdose not complicated by additional medical or social factors.

The ideal patient is one that is beginning to experiencing withdrawal symptoms of mild to moderate severity following reversal with naloxone or due to absence of use. The patient should be awake and alert enough to participate in shared decision-making about the initiation of therapy.

It is best to initiate buprenorphine while patients are experiencing some degree of withdrawal so that the agonist effects produce a net-positive feeling, providing patients with a sense of relief and comfort likely to strengthen motivation for continued engagement.

Buprenorphine should not be given to patients who are already on methadone, as this could lead to worse withdrawal reactions. It should also be avoided in patients who appear “sick,” suggesting underlying metabolic or infectious processes, intoxication, or co-ingestion. It should not be used as primary therapy for severe withdrawal.

Although studies have demonstrated utility for validated scoring systems to assess withdrawal severity, it is sufficient to evaluate a patient’s overall clinical appearance and decide to treat based on gestalt.

What is the best dose to initiate buprenorphine treatment?

There is no single agreed-upon dosing regimen. Many X-waiver courses promote a “by-the-book” approach of 2-4 mg every 2 hours to a max of 8 mg on the day of initiation.

Taking into account that prescription medications and street drugs continue to increase in potency, however, starting with small doses may leave the patient continuing to feel symptomatic and discourage use. The goal of treatment should be to create a positive experience that will facilitate continued MAT.

Evolving dosing regimens recommend taking into account the patient’s level of use to determine an initial dose. Data supports that individuals are rather good about classifying themselves as light, medium, or heavy users.

Light user: 4 mg
Medium user: 8 mg
Heavy user: 16 mg

If the decision is made to start on the lower end, a commitment should be made to re-evaluate the patient 30 minutes after the first dose to determine the need for additional medication. Avoid leaving your patients suffering in continued withdrawal.

Remember, even though the patient may end up in a good place, the initial displacement of the opiate or reversal agent may inherently cause discomfort or pain as the opiate receptor is unbound.

What issues remain?

Improved reversal practices and more appropriate dosing of reversal agents will improve the patient experience as triggered withdrawal symptoms can be lessened in severity. There exists a large variability in the amount of naloxone given by pre-hospital and ED providers.

Interested in more of the ACEP-EQUAL Podcast?

By Moises Gallegos, MD MPH|2021-09-15T11:31:08-07:00Dec 18, 2020|Academic, ACEP E-QUAL|

ACEP E-QUAL: ACEP Non-STEMI Clinical Policy

In 2018, the American College of Physicians (ACEP) released a Clinical Policy with management recommendations for patients presenting to the emergency department (ED) with concern for non-ST-elevation myocardial infarction (NSTEMI). Dr. Jason Woods hosted an episode of the ACEP E-QUAL Network podcast highlighting key aspects of the new policy. Dr. Woods was joined by lead writer Dr. Christian Tomaszewski from the University of California San Diego, and Dr. Michael Ross, Director of the Chest Pain Center at Emory University. Below are show notes reviewing the recommendations and the process involved in creating the clinical policy.

How is a clinical policy different than a practice guideline?

The National Guideline Clearinghouse (NGC), a public resource initiative of the Agency for Healthcare Research and Quality (AHRQ), provides rules and frameworks for evidence-based clinical practice guidelines. ACEP refers to clinical practice guidelines in Emergency Medicine (EM) as policies to denote the more prescriptive design process.

What was the process of drafting the policy?

Development of the 2018 ACEP NSTEMI Clinical Policy was a 2-year “labor of love.” Writers, methodologies, and committee members were required to be free from both financial and intellectual conflict of interest.

The clinical policy is a result of a systematic review and critical analysis of available medical literature. Clinical studies were graded on robustness, design, and class of evidence according to the ACEP policy development process which includes internal and external review.

Recommendations were categorized as reflecting high clinical certainty (Level A), moderate clinical certainty (Level B), or mixed clinical certainty (Level C) due to the heterogeneity of results, unclear effect magnitude, bias, among other factors.

What questions did the policy address?

Four critical questions were decided by consensus methods to address the evaluation and management of adult patients presenting to the ED with concern for NSTEMI.

1) If ST-elevation myocardial infarction is excluded, can a combination of bedside and laboratory evaluation in the ED identify patients at low risk for major adverse cardiac events (MACE)?
Level B recommendation: History, ECG, Age, Risk Factors, Troponin (HEART) score < 3 can be used as a clinical prediction tool for a 30-day MACE miss rate between 0-2%.
Level C recommendation: Thrombolysis in Myocardial Infarction (TIMI) score can be used to predict risk of 30-day MACE.

2) Can repeat Troponin testing in the ED be used to identify patients at low risk for MACE?
Level C recommendations:

- Conventional troponin testing at hour 0 and 3 in low risk (HEART score < 3) patients can predict and acceptable low risk for 30-day MACE.
- A single high-sensitivity troponin less than the detectable limit on arrival to the ED or negative serial high-sensitivity troponin at hour 0 and 2 is predictive of a low rate of MACE.
- Patients deemed to be low risk with a non-ischemic ECG and negative high-sensitivity troponin at 0 and 2 hours can be considered low risk for 30-day MACE, allowing for accelerated discharge from the ED.

3) In patients who have been ruled out for acute coronary syndromes (ACS), does advanced cardiac provocative testing prior to discharge from the ED reduce MACE?
Level B recommendation: Do not routinely use advanced cardiac testing in low-risk patients who have been ruled out for ACS to further reduce 30-day MACE.
Level C recommendation: Arrange follow-up in 1-2 weeks for low-risk patients in whom ACS has been ruled out. If unable to arrange follow-up, consider observation and advanced testing prior to discharge.

4) Should patients with NSTEMI receive antiplatelet therapy in addition to aspirin in the ED?
Level C recommendation: P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors can be given in the ED or delayed until cardiac catheterization.

What questions remain?

The clinical policy does not address the “delta factor” involved in assessing changes to the cardiac marker levels that may be seen with repeat testing at set time points.
Duration of pain was not discretely addressed, and differences in real-world practice can exist depending on whether the time of onset or time of presentation is considered for defining repeat testing and observation length.
Shared decision-making was not factored into the selection of management steps.

Important points for consideration:

The 2018 ACEP Clinical Policy for NSTEMI was written for the evaluation of patients with suspicion for ACS who presented with chest pain. It does not apply to those presentations of ACS that are considered atypical in nature.

Read a more in-depth summary of the ACEP Clinical Policy on ALiEM.

Interested in more of the ACEP-EQUAL Podcast?

By Moises Gallegos, MD MPH|2021-09-15T11:34:21-07:00Dec 7, 2020|Academic, ACEP E-QUAL, Cardiovascular|

ACEP E-QUAL: The Electronic ICU

Building on already increasing interest in telehealth, the COVID-19 pandemic accelerated the development and implementation of telemedicine services in a variety of clinical settings. In 2018, Dr. Jason Woods hosted an episode of the ACEP E-QUAL Network podcast highlighting the creation of an electronic intensive care unit (eICU) through Emory Healthcare. In this episode, Dr. Tim Buchman and Critical Care Nurse Cheryl Hiddelson share their innovative approach to delivering critical care services via telehealth. We present highlights from this discussion below.

What is an eICU?

The eICU allows for critical care oversight, without having to be on site. It provides comprehensive monitoring and data analysis and online audio or video support for patients and families. Utilizing advanced information technology (IT) platforms and approaching with a business strategy, telehealth allows for innovative ways to provide critical care services remotely.

Why is there a need for an eICU?

The US population is aging, with the number of Americans age 65 or older increasing steadily. Demand for critical care services increases with age. The availability of critical care physicians is limited in large areas of the US. Similarly, as more nurses are reaching retirement than those entering the workforce, critical care providers are becoming hard to come by. Recruiting and maintaining critical care providers is only one part of the issue, with staffing on nights, weekends, and holidays creating a constant challenge. Telehealth poses a contemporary solution to the scarcity of healthcare providers.

What does the eICU setup look like?

The eICU is akin to airline control towers. There is 24/7 coverage by nursing and physician staff, overseeing more than a hundred beds. Various screens facilitate a “sentry” role in which surveillance monitoring algorithms allow staff to detect problems possibly even before the bedside staff. The eICU integrates bedside monitor data with additional system-wide data to create different views of what is occurring in the unit being monitored. Staff can track discharge readiness and filter lists by system or condition.

Camera sessions allow for bi-directional communication with patients and families, but also for just-in-time-training with staff as well as consultation with specialists.

What unique challenges has the eICU been able to address?

On-site advanced practice providers (APPs) such as physician assistants, nurse-practitioners, can be supervised by critical care nurses and physicians to provide in-person care.
Alternative staffing from geographic areas that are in a different time zone can help fill night shifts. The Emory group used travel nurses and physicians who were stationed in Australia.
Distance and delay to care become irrelevant when an intensivist can be available 24/7.

What benefits have been observed with the eICU?

The Emory eICU was able to realize decreased mortality, decreased transfer rates, decreased length of stay, and an increase in patient experience metrics for the hospitals it covered compared to other local facilities. Analysis of costs suggested savings of thousands of dollars per patient and increased revenue for small community hospitals that could retain and increase their daily census of critical care patients.

Can this concept be applied to Emergency Medicine?

There may be a role in applying telehealth data monitoring to emergency department waiting rooms in an attempt to identify patients at high risk for sudden deterioration or decompensation.

Interested in more ACEP-EQUAL podcasts?

Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.

By Moises Gallegos, MD MPH|2020-12-03T19:56:27-08:00Dec 4, 2020|Academic, Critical Care/ Resus, Podcasts|

Treating Blood Pressure in Intracranial Hemorrhage

Blood pressure control in the setting of ischemic stroke has a clearly recognized benefit in patient outcomes. The impact of blood pressure control in hemorrhagic stroke is not as well understood. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with Dr. Latha Ganti (University of Central Florida College of Medicine). Dr. Ganti addressed the evidence behind recommended blood pressure targets and the available medications to achieve control. We present highlights from this discussion with Dr. Jason Woods.

What is the goal of blood pressure control in hemorrhagic stroke?

Management of blood pressure in intracranial hemorrhage (ICH) raises questions about the benefit of limiting hematoma expansion while maintaining cerebral perfusion. While it seems intuitive that hypertension should be controlled to limit hematoma expansion, patients with hemorrhagic stroke may be dependent on higher blood pressures for adequate perfusion.

Does lowering blood pressure lead to perihematomal ischemia?

ICH Adapt studies did not show evidence of decreased cerebral blood flow in perihematomal tissue and demonstrated that there is likely preservation of autoregulation which prevents ischemia [1].

Does lowering BP help prevent hematoma expansion and improve outcomes?

The risk of hematoma expansion is highest within the first couple of hours following initial bleeding. Hematoma expansion is clearly associated with worse outcomes. Scoring tools exist to estimate the risk of hematoma expansion. The “spot sign,” seen on source images from a computed tomography angiogram of the brain, suggests an area of dynamic bleeding.

ICH ADAPT: no difference in hematoma expansion or clinical outcome with acute blood pressure lowering [2].
INTERACT 2: intensive lowering of blood pressure did not result in a significant reduction in mortality or severe disability [3].
ATACH 2: intensive lowering of blood pressure did not improve functional outcomes but was associated with increased renal dysfunction [4].

What is the optimal systolic blood pressure (SBP) target?

AHA Guidelines 2015

ICH patients with SBP 150-220 mmHg, lower to 14 mmHg is safe
ICH patients with SBP > 220 mmHg, aggressive reduction with continuous infusion may be reasonable

So what’s the right thing to do? If data suggests that lowering may not be as beneficial, what should the target blood pressure be?

Target SBP 140-160 mmHg is a reasonable target

What medications are preferred for blood pressure control in ICH?

The ideal agent for blood pressure management in ICH would have a quick onset, but short duration, to allow titration.

Recommended first-line:

Labetalol
- Onset < 5 min
- Duration of effect 2-4 hr
- IV bolus dose: 20 mg, followed by 20-80 mg every 10 min to a total dose of 300 mg.
- Infusion dose: 0.5 mg-2 mg/min
- Avoid in: asthma, COPD, heart failure, AV block
Nicardipine
- Onset 1-2 min
- Half-life ~ 40 min
- Infusion dose: 0.5-1 mcg/kg/min, max 3 mcg/kg/min
Clevidipine
- Onset 1-4 min
- Duration of effect 5-15 min
- Infusion dose: 1 mg/hr, up to 21 mg/hr, titrate by 2.5 mg/hr every 5-10 min
- Avoid in: severe aortic stenosis, and lipid metabolism dysfunction or known allergy to eggs or soy (delivered as lipid emulsion)

Available second-line (mostly off-label, not preferred)

Esmolol
Fenoldopam
Hydralazine
Enalaprilat

Conclusions

When it comes to blood pressure: keep it simple.

Target SBP 140-160 mmHg
Top three drugs: Labetalol, Nicardipine, Clevidipine

Although labetalol has common contraindications, it is available as a bolus dose. In a clinical setting where drips may not be readily available, Labetalol can be easier to get.

Interested in more ACEP-EQUAL podcasts?

Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.

References

Butcher K, Jeerakathil T, Emery D, et al. The Intracerebral Haemorrhage Acutely Decreasing Arterial Pressure Trial: ICH ADAPT. Int J Stroke. 2010;5(3):227-233. PMID: 20536619
Butcher KS, Jeerakathil T, Hill M, et al. The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial. Stroke. 2013;44(3):620-626. PMID: 23391776
Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage. N Engl J Med. 2013;368(25):2355-2365. PMID: 23713578
Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016;375(11):1033-1043. PMID: 27276234

By Moises Gallegos, MD MPH|2020-10-09T09:47:57-07:00Oct 23, 2020|Academic, Emergency Medicine, Neurology|

Anticoagulant Reversal in Hemorrhagic Stroke

Acute management of cerebrovascular accidents can be challenging enough, but questions about anticoagulant reversal in the setting of hemorrhagic stroke add another layer of complexity. The ACEP E-QUAL Network podcast, a partnership with ALiEM to promote clinical practice improvements, reviewed this topic with Dr. Joshua Goldstein (Massachusetts General Hospital, Harvard Medical School). Dr. Goldstein addressed common anticoagulants and their reversal agents, summarizing available literature to inform clinical practice. We present highlights from this discussion with Dr. Jason Woods.

What is the goal of anticoagulant reversal?

Since it is impossible to go back in time to prevent intracranial hemorrhage (ICH), the focus of management for hemorrhagic stroke should be to prevent further bleeding and allow brain tissue an opportunity to recover. The goal of anticoagulant reversal in patients with ICH is to decrease ongoing bleeding.

Warfarin

Warfarin is a vitamin K antagonist. Since vitamin K is required for the processing of coagulation factors II, VII, IX, and X, patients on warfarin have decreased amounts of these factors in circulation. To increase the availability of these factors, countering the effect of warfarin therapy can be two-fold:

Replenish vitamin K to allow the production of new factors.
Provide replacement of these factors directly.

Vitamin K supplementation will not provide immediate effect, and it may take up to 24 hours for the production of new coagulation factors. While it should be given early, patients also require factor replacement acutely.

Fresh frozen plasma (FFP) or prothrombin complex concentrate (PCC) can be given to supplement coagulation factors.

FFP carries each of the 4 needed factors in addition to other clotting factors.
- The cost of FFP is low.
- Transfusion will take some time as it will require ~ 1 L volume.
PCC, marketed as Kaycentra in the US, consists of concentrated Factor II, VII, IX, X, and proteins C and S.
- The cost of PCC is higher.
- Transfusion is quick, ~70 mL, and leads to rapid correction of INR.

Studies have shown PCC to be associated with faster INR reversal, less ICH expansion, and a non-statistical trend toward decreased mortality [1]. PCC does carry a theoretical risk of thromboembolism given the rapid correction, but no evidence exists to suggest that this is the case.

Direct Oral Anticoagulants (DOACs)

There are 2 categories of DOACs:

Factor II inhibitors (e.g., dabigatran)
Factor Xa inhibitors (e.g., rivaroxaban, apixaban, edoxaban)

Approach to reversal: remove the inhibitor to allow normal function of already existent Factor II or Xa

Time
- Time can be thought of as a reversal agent. Most DOACs have a half-life ~12 hours. If the timing of the last dose is known and it was hours ago, there may not be much medication left to reverse.
Monoclonal antibodies
- Reversal of dabigatran can be achieved with the use of a monoclonal antibody, idarucizumab, to bind up circulating inhibitor.
- Reversal of Factor Xa inhibitors can similarly be attempted with the use of monoclonal antibody andexanet. Andexanet is notably more expensive than idarucizumab.
PCC
- PCC can be used off-label to outcompete circulating inhibitor with extra coagulation factors and increase the number of functional factors.

It should be noted that there are no reliable tests for measuring DOAC activity.

Dual Antiplatelet Therapy (DAPT)

The most common agents are aspirin and Plavix (clopidogrel). The issue with patients on these antiplatelet agents is not a lack of platelets, but the presence of medication that suppresses normal platelet function. Theoretically, if one could provide extra platelets, the inhibiting agent could be saturated and the remaining platelets provide some functional activity.

The PATCH trial demonstrated, however, that platelet transfusion led to significantly worse outcomes [2]. While there is no readily available reversal agent for DAPT, platelet transfusion should be avoided. In fact, observational data suggest that patients on single antiplatelet therapy don’t fare worse and may not need reversal like those with DAPT [3].

Conclusions

Warfarin reversal

IV vitamin K + PCC (or FFP)

Dabigatran reversal

Specific agent: Idarucizumab
Non-specific agent: PCC

Factor Xa inhibitor reversal

Specific agent: Andexanet
Non-specific agent: PCC

Antiplatelet reversal

No available agent
Transfusion of platelets associated with worse outcomes.

Interested in more ACEP-EQUAL podcasts?

Listen to the other ACEP E-QUAL podcasts on our Soundcloud account.

References

Steiner T, Poli S, Griebe M, et al. Fresh frozen plasma versus prothrombin complex concentrate in patients with intracranial haemorrhage related to vitamin K antagonists (INCH): a randomised trial. Lancet Neurol. 2016;15(6):566-573. [PMID: 27302126]
Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet. 2016;387(10038):2605-2613. [PMID:27178479]
Khan NI, Siddiqui FM, Goldstein JN, et al. Association Between Previous Use of Antiplatelet Therapy and Intracerebral Hemorrhage Outcomes. Stroke. 2017;48(7):1810-1817. [PMID:28596454]

By Moises Gallegos, MD MPH|2024-04-19T21:52:51-07:00Oct 16, 2020|Academic, Emergency Medicine, Neurology|

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