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For Evaluation Only.

20.1 A 22-year-old woman who experienced pain


and swelling in her right leg presented at the
emergency room. An ultrasound study showed
thrombosis in the popliteal vein. The patient, who
was in her second trimester of pregnancy, was
treated for 7 days with intravenous unfractionated
heparin. The pain resolved during the course of
therapy, and the patient was discharged on Day 8.
Which one of the following drugs would be most
appropriate out-patient follow-up therapy for this
patient, who lives 100 miles from the nearest
hospital?
A. Warfarin.
B. Aspirin.
C. Alteplase.
D. Unfractionated heparin.
E. Low-molecular-weight heparin (LMWH).

Correct answer = E. LMWH has a reliable dose


response and can be administered subcutaneously by
selected patients who have been taught home
injection technique. LMWH does not cross the
placenta and shows no teratogenic effects. By
contrast, warfarin is teratogenic and is
contraindicated in pregnant patients. Aspirin, which
inhibits platelet aggregation, has little effect on
venous thrombosis, which is composed of fibrin with
only a few platelets. Alteplase is not indicated for
deep-vein thrombosis.
Edited by Foxit Reader
Copyright(C) by Foxit Software Company,2005-2008
For Evaluation Only.

20.2 A 60-year-old man is diagnosed with deep-


vein thrombosis. The patient was treated with a
bolus of heparin, and a heparin drip was started.
One hour later, he was bleeding profusely from the
intravenous site. The heparin therapy was
suspended, but the bleeding continued. Protamine
was administered intravenously, and the bleeding
resolved. The protamine:
A. Degraded the heparin.
B. Inactivates antithrombin.
C. Activates the coagulation cascade.
D. Activates tissue-plasminogen activator.
E. Ionically combines with heparin.

Correct answer = E. Excessive bleeding may be


managed by ceasing administration of the drug or by
treating with protamine sulfate. Infused slowly,
protamine combines ionically with heparin to form a
stable, inactive complex.
20.3 A 54-year-old male with a prosthetic aortic
valve replacement complained to his family physician
of black and tarry stools. Physical examination and
vital signs were unremarkable except for
subconjunctival hemorrhages and bleeding gums.
Stools tested positive for heme, and hematuria was
observed. The patient has been receiving oral
warfarin since his valve replacement 1 year earlier.
Prothrombin time was found to be significantly
elevated. Which one of the following therapies
would provide the most rapid recovery from the
observed bleeding secondary to warfarin treatment?
A. Intravenous vitamin K.
B. Transfusion of fresh-frozen plasma.
C. Intravenous protamine.
D. Immediate withdrawal of warfarin treatment.
E. Intravenous administration of anti-warfarin
antibodies.

Correct answer = B. Whole blood, frozen plasma, or


plasma concentrates of the blood factors may be
employed to rapidly arrest hemorrhaging. Minor
bleeding may be treated by withdrawal of the drug
and administration of oral vitamin K1; severe
bleeding requires greater doses of the vitamin given
intravenously. However, reversal following
administration of vitamin K takes approximately 24
hours. Protamine is used to neutralize an overdose
of heparin, not an overdose of warfarin. Immediate
withdrawal of warfarin treatment will not have an
immediate effect, because the anticoagulant effects
of warfarin last between 5 and 7 days.