Warfarin and head injury/Protein C

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Joe,

Warfarin might induce skin necrosis in such patients and severe
paradoxal thrombosis - I had one case like that before.
How is her coagulation profile? protein C activity? PT? ATIII? protein
S level? vitamin K dependent coagulation factors? Does her protein C
levels respond to vitamin K administration? Vitamin K deficiency is a
cause of protein C deficiency too, as well as neoplasias.
Has she been submitted to an APC resistance assay?Was she tested for
factor V laten and prothrombin mutations? What about antiphospholipid
and anticardiolipin antibodies? Are her factor VIII and IX levels
elevated?
Also, fibrinolysis markers are elevated? TAT, fibrin degradation
products, fragment 1+2, D dimer? This is important to see if she is
actively forming clots.

Regarding warfarin therapy: I would not start it with low protein C levels.
I would give her protein C concentrates or start it with prophylactic LMWH doses
A common protein C concentrate administration protocol is a test dose
at 10 IU/kg; follow by a bolus (100 IU/kg) and then as continuous
infusion (10-15 IU/kg/h), adjusted to give a protein C level of 80-120
IU/mL - this is safe enough to initiate warfarin therapy.

My 2 brazilian worthless cents.

claudia


On 4/2/06, Joe Nold <jnoldscarmaker at yahoo.com> wrote:
> On a tangent, I have an 80 y/o female w/ protein C deficiency with a history
> of both upper extremity and lower extremity DVT.  She was admitted after a
> fall with a 2cm SDH, INR of 2.
>
>   Any recommendations on future anticoagulation/filter(s) in this elderly
> lady with a history of falls (syncope work up completely negative to date.
>
>   As a bonus, her husband is a former ER doc, and 3 daughters are all
> internists.
>
>   Any help would be appreciated.
>
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