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COVID-19 Vaccine Induced Thrombosis/Thrombocytopenia (VITT)

Inclusion Criteria [Both of]:

  1. Received AstraZeneca (AZ) COVID 19 vaccination within 28 days (typically 4-28 days from immunisation)
  2. New Onset thrombocytopenia (PLTs <150×109/L) – with or without Thrombosis

Initial Investigations:

  • FBC– specifically to confirm thrombocytopenia <150x 109/L
  • Coagulation screen and D Dimers
  • Blood film to confirm true thrombocytopenia and identify alternative causes

PROBABLE CASE: (ALL 3 criteria)

  1. Received AZ COVID 19 vaccination within 28 days
  2. New Onset thrombocytopenia (PLTs <150×109/L)
  3. D Dimers > 2000 mcg/L

URGENT Scan to confirm the suspected clot.

[If patient doesn’t fit “PROBABLE CASE” proceed to usual treatment]


Condition specific advice:

Central clot:

  • inc. Cerebral Venous Sinus Thrombosis (CVST), Pulmonary Embolis (PE), Splenic, Proximal DVT
  • Discuss with Haematologist
  • Admit Medicine

Suspected DVT (scan unavailable):

  • Treat with Rivaroxaban (Do Not use Dalteparin/LMWH)
  • Request Ultrasound
  • Return AAU Next Day
  • Safety-net Advice

Confirmed Distal DVT (Not above inguinal ligament)

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Thrombocytopenia only

  • Platelets  <100×109/L – Discus with Haematology
  • Platelets ≥100×109/L – Treat as normal

Treatment (will be directed by Haematology & Specialist teams):

Avoid:

  • Heparin Based anticoagulants
  • Antiplatelets
  • Platelet Transfusion

May Require:

  • IV immunoglobulin
  • Steroid
  • Anticoagulation with: DOAC, Fondaparinux, Argatroban

Further reading

 

Malignant/Accelerated Hypertension

There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

Patient has both:

  1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
  2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

Read more

Methaemoglobinaemia

Q: Why are Smurf’s Blue? 

A: Methaemoglobin (MetHb) of course!

MetHb is produced by oxidisation of the Iron in Haemoglobin (Hb) from Fe2+ to Fe3+

Fe3+ prevents Hb carrying oxygen (thus produces symptoms of hypoxia)

Often due to chemical ingestion, but may also be genetic

Treated with Methyl Blue & supportive measures

Read more

Hypernatraemia

Hypernatraemia is a not a common presentation in ED, as intense thirst often prevents significant hypernatraemia in neurologically intact individuals. So… Mortality rates are high (20-70%) and the severity of hypernatraemia has been shown be an independent predictor of mortality.

However, there is little good data on hypernatremia to base guidance on, and definitions vary within the literature

Read more