witheld aspirin during chest pain

[BushyFromOz]

hi all, basically need some guidance as i am double guessing myself

Went to a pt today who appears to be in renal failure,for past 2/7 pt has had increasing lethargy and weakness, nausea and vomiting, cool, pale and diaphoretic, B/P 70/50, HR 100, RR 16, SP02 80 on room air but no SOB and chest is clear, Temp is 36.3 and BSL is 7.6 mmol, no 12 lead but sinus rhythm on the monitor (wonder where the Af went?). Has a Hx of renal failure, was on dialysis until 5 years ago when she had a kidney transplant, has CCF, HT, Af, IHD and an NIDDM. Anyway, this pt is also complaining of this jaw pain and i start thinking awesome, she has been having prodromal symptoms for the past 2 days and now she is having the big one, but I decide to with hold aspirin due to her INR being 6.5

My question is this, do you feel it is reasonable to with hold aspirin in suspected AMI based on INR in the world of paramology?

Cheers

[scott33]

I decide to with hold aspirin due to her INR being 6.5

And had you given the Aspirin, the INR would still be 6.5

They have no direct relationship.

[chbare]

And had you given the Aspirin, the INR would still be 6.5

They have no direct relationship.

ASA affects platelets, a good point to emphasise as these other labs are related to clotting factors. However, with an INR that elevated, one has to assume some sort of factor problem and altering the platelets in the pre-hospital environment may not be the best way to go.

Take care,

chbare.

[mobey]

My question is this, do you feel it is reasonable to with hold aspirin in suspected AMI based on INR in the world of paramology?

Bushy: Please do not take this the wrong way, as I have read your posts for years and respect your competence, but why are you asking how we "feel"?

EBM is not about opinion, it is about science. Before you changed your standard Tx did you look into how INR is affected by ASA? Do you have a clear understanding of the clotting cascade and where INR levels and ASA fit in?

Did you reference the sources?

I cannot answer your question because I have not studied INR.

[DartmouthDave]

Hello,

Sepsis could be an option as well. Renal transplants are high risk due to the immunosuppression medications (i.e. Tacrolimus, ect...) they need to take. MI and cardiogenic shock is high on the list as well. Acidosis from the renal failure. A whole pile of problems here. I think the resp failure (SpO2 of 80%) is a perfusion issue as well.

Holding the ASA was a good idea.

-->Just wondering. How did you know the INR was 6.5?

-->Was this patient on Warfarin for the Afib?? (INR 2-3 is goal for Afib) That may account for the elevated INR.

-->What is this lady colour? Eyes? Jaundice? Liver issues can also account for the INR.

Just wonder how things worked out for you. Any follow up from the ED?

Cheers...

[BushyFromOz]

Bushy: Please do not take this the wrong way, as I have read your posts for years and respect your competence, but why are you asking how we "feel"?

EBM is not about opinion, it is about science. Before you changed your standard Tx did you look into how INR is affected by ASA? Do you have a clear understanding of the clotting cascade and where INR levels and ASA fit in?

Did you reference the sources?

I cannot answer your question because I have not studied INR.

Fair enough, the pt was never getting aspirin anyway due to a severe headache from a fall at the same time, was just seeing what others views on it was. I take the EBM thing, was always going to look this up but not last night as i finished work late and quite frankly could not have been bothered at 2100

Just thought I'd throw it out there.

[BushyFromOz]

ASA affects platelets, a good point to emphasise as these other labs are related to clotting factors. However, with an INR that elevated, one has to assume some sort of factor problem and altering the platelets in the pre-hospital environment may not be the best way to go.

That was sorta my line of thinking. While she is on warfarin her INR has steadily been elevating despite continually reducing her warfarin dose. The INR level was taken the morning that i picked this patient up so it is current.

And had you given the Aspirin, the INR would still be 6.5

They have no direct relationship.

understand that, but that's not what i asked

[BushyFromOz]

Gee, with the amount of post bashing that goes on around here i thought i would be getting a real schalacking by now

[Richard B the EMT]

Would somebody who is ALS explain to the BLS guy what "INR" is?

[JPINFV]

INR stands for "International Normalized Ratio" and is a measure of the extrinsic clotting cascade. It's what's used to determine dosing for Warfarin (Coumadin).