December 22, 2023

Welcome back to UH EMS-I’s Pharmacy Phriday. In the last installment, we reviewed the use of Brilinta during an acute MI. In this installment, we will also review the use of Heparin within that protocol. Both medications help to meet the treatment goal in an acute MI by reducing clotting and limiting the size of the infarcted area but in different ways. 

Both are often referred to as “blood thinners,” though neither thin the blood. Antiplatelets, Brilinta being one of them, interfere with the binding of platelets, or the process that forms what is called a platelet plug. Anticoagulants, Heparin being one, interfere with the proteins, or factors, in the blood that are involved with the coagulation process. Different anticoagulants interfere with other factors to prevent clotting.

While Aspirin and Brilinta, two medications reviewed in previous weeks, work on the platelets, Heparin rapidly inactivates thrombin, which normally causes the formation of fibrin. Blocking this cascade prevents the formation of clots and prolongs the clotting time of blood. The early use of Heparin in the prehospital setting helps to reduce the size of the infarct and, in turn, is associated with improved survival of the MI patient.

Heparin is a high-risk medication and can potentially cause severe bleeding. The medication is usually guided by anticoagulation lab studies (PT and PTT). Although these tools are unavailable in the prehospital setting, using Heparin in certain cases has demonstrated benefits that exceed the risks of starting therapy without these baseline studies. Monitoring and maintenance dosing are often implemented as the patient’s care continues in the hospital setting. 

Because of its possible side effect of bleeding, Heparin should not be given to anyone with active bleeding, a trauma or stroke patient. UH protocols do not allow the administration of Heparin in cases of a stimulant-induced STEMI, in a pediatric patient, for pregnant women, in cases of hypertension, when a patient has had surgery within the last 14 days, or in cases of aortic dissection. Some texts suggest caution in its use with the elderly and chronic alcoholic patient as well.

Heparin should not be administered if the patient is already taking an anticoagulant such as Warfarin, Eliquis, Xarelto, Pradaxa, etc. A list of common anticoagulant medications is provided in the protocol’s “key points” for reference. 

To avoid inappropriate administrations, the same STEMI checklist listed in the protocol that must be used before administering Brilinta is also used before administering Heparin. As a review, the items included in that checklist are:

• No sharp ripping/tearing chest or back pain (possibly indicating an aortic dissection)

• No altered mental status

• No known bleeds or concern of bleeding (i.e., GI bleeds, vomiting blood, blood in urine, etc.)

• No trauma or post-arrest following CPR

• No severe headache

• If STEMI mimickers are present, you must consult medical direction

As was mentioned with the use of Brilinta, Heparin is approved in the UH protocols for administration in a confirmed STEMI. Remember, when in doubt, contact medical direction.

Dosing for Heparin is a one-time dose of 60 units/kg given IV/IO, with a maximum dose of 4000 units (this is the equivalent of a patient that weighs 147 lbs.). Be alert! Heparin is normally provided in a 1 ml vial that contains 5000 units. The max dose allowed per the protocols would equal just 0.8 ml of that concentration.

Happy Holidays to you and yours! Have a safe week!

Sincerely,



The UH EMS-I Team

University Hospitals

October 14, 2022

Dear Colleagues,

During this past week, many across the nation have celebrated the 100th anniversary of NFPA Fire Prevention Week.  Fire Prevention Week is observed each year during the week of October 9th in commemoration of the Great Chicago Fire that killed over 250 people and destroyed thousands of structures. This year’s theme was “Fire Won’t Wait – Plan Your Escape.”  One of the points of the campaign includes the fact that in a fire, mere seconds can mean the difference between a safe escape and a tragedy. The medication we review during this week’s Pharmacy Phriday, Heparin, is also about quick action, but during an Acute MI. 

During an MI, platelet aggregation and coagulation of blood in the coronary arteries can cause death to the myocardium.  While Aspirin and Brilinta, two medications reviewed in previous weeks, work on the platelets, Heparin rapidly inactivates thrombin which normally causes the formation of fibrin.  Blocking this cascade prevents the formation of clots and prolongs the clotting time of blood. The early use of Heparin in the prehospital setting helps to reduce the size of the infarct and, in turn, is associated with improved short-term and long-term survival of the MI patient.

Heparin is a high-risk medication and can potentially cause severe bleeding.  The medication is usually guided by anticoagulation studies (PT and PTT).  Although these tools are unavailable in the prehospital setting, the use of Heparin in certain cases has demonstrated benefits that exceed the risks of starting therapy without these baseline studies. Monitoring and maintenance dosing are often implemented as the patient’s care continues in the hospital setting.  As a guideline for providers in the prehospital setting, there are many contraindications listed for use within EMS protocols.

Because of its possible side effect of bleeding, Heparin should not be given to anyone with active bleeding, a trauma, or a stroke patient.  UH protocols do not allow the administration of Heparin to children, pregnant women, in cases of hypertension, when a patient has had surgery within the last 14 days, or in cases of aortic dissection.  Heparin should not be administered if the patient is taking an anticoagulant regularly (such as Warfarin, Eliquis, Xarelto, etc.  A list of such medications is provided in the protocol’s “key points” with the antiplatelet list for reference.)  Some texts suggest caution in use with the elderly and chronic alcoholic patient.

Heparin is approved in the UH protocols for administration in a confirmed STEMI patient who is being transported to a UH facility that allows offline medical control. (When in doubt, contact the receiving facility prior to administration.)  Dosing is 60 units/kg with a maximum dose of 4000 units (this is the equivalent of a patient that weighs 147 lbs.).  Be alert! Heparin is normally provided in a 1 ml vial that contains 5000 units.  The max dose allowed per the protocols would equal just 0.8 ml of that concentration.

Just as advanced planning and preparation are critical to escaping a home fire, so is planning and preparation important for these types of EMS calls. Know your protocol!  Know your drug box!  Time is of the essence.

Till the next edition of Pharmacy Phriday, stay safe!

Sincerely,

The UH EMS-I Team

University Hospitals