Now let's look at heparin
It's a little newer than unfractionated
heparin and it's got some cool things.
Enoxaprin or fondaparinux, those are 2 examples.
So, this is really replacing
unfractionated heparin for reasons
that we talk about specifically in
the Unfractionated Heparin Video.
So, this is the frontline therapy.
You'll see, most often, your patients
are on a low-molecular-weight heparin.
Just like unfractionated heparin,
cannot be given as a pill.
It has to be given SubQ.
Now, we give that in the patient's abdomen,
and I told you from my personal experience,
the stick was not bad at all,
it just a little SubQ stick.
But for me, personally, this
medication burned like fire.
And then your patient will have
probably little areas of bruising
everywhere you've given the injection,
or they've given themselves the injection.
Help your patients expect that,
know that it's going to happen,
and just use it as marker to know that
you're rotating your sights appropriately.
So, let's review how low-molecular-weight heparin
is different from unfractionated heparin,
because low-molecular-weight heparin is making
by breaking unfractionated
heparin into smaller pieces.
Remember, unfractionated heparin is huge, but
when we do low-molecular-weight heparin,
we've just taken that big one and
broken it into smaller pieces.
heparin has some preferences.
It prefers to more specifically
inactivate factor Xa,
versus more widespread
plasma proteins and tissues
that you'll see with unfractionated heparin.
So, low-molecular-weight plasma
levels are more predictable.
So that's why we can give them weight based.
Remember, if your patients are obese, like
I was when I received this medication,
I actually had to have 2 syringes
of medications when I gave it.
So, low-molecular-weight heparin is more
predictable than unfractionated heparin.
We give it on a weight-based, fixed dose,
and we usually don't have to do lab work.
We can use heparin anti-Xa levels
if we think there's a problem,
but usually, this can be given simply
weight-based, it's very predictable,
and we can keep our patients very safe.
Now, the reversal for heparin
is protamine sulfate.
It's always good for you to know if we have a drug,
if we get too much of it for our
patient, what's the reversal agent?
Remember, if someone was on
warfarin, we would give what?
But for heparin, we would use protamine sulfate.
That reverses the anticoagulant effects of
heparin because it binds to the heparin.
Now we can use this before or after surgery,
if we have problems, after dialysis.
Or if someone is excessively
bleeding from heparin,
we would give the reversal agent,
which again, is protamine sulfate.
We give it IV and it has rapid
onset within 5 minutes.
So we can use it with unfractionated and
low-molecular-weight heparin overdosing.
So while we're less likely to have an
overdose with low-molecular-weight heparin,
we can give this reversal agent
protamine sulfate with both of them.
Now, I want you to note at the bottom,
we have a note there for you with a
triangle with the exclamation point.
If protamine sulfate is given to a
patient who hasn't received heparin,
it'll have this slight anticoagulant effect.
Isn't that amazing?
Now, I don't know why you would give protamine
sulfate to a patient who hadn't had heparin,
but you will have a slight anticoagulant effect.
So this reversal agent, if you're on heparin,
will actually cause some slight
anticoagulation if you receive it
and you haven't been on heparin.
But protamine sulfate plus heparin equals
neither drug having an anticoagulant effect.
So that's just something for you to kind
of keep in mind, just a nice-to-know.
But it reinforces that concept that
if we have a heparin overdose,
meaning the patient's lab works
are outside of normal values,
they're too high, or the patient is showing
us signs of bleeding, which just for fun,
pause and see if you can list all
the clinical signs and symptoms
that you can think of that our patient was
getting into risk of inappropriate bleeding.
I hope you were able to list several things
like bleeding gums, blood in your body fluids.
If the patient bumps their head and
they have a change in consciousness,
if they feel short of breath,
if they are having chest pain.
Those are some of the more serious
ones that you can deal with
when somebody's on anticoagulant therapy.
But protamine sulfate plus heparin
means neither of those drugs
will cause an anticoagulant effect.
So this is a review slide.
So let's pause and take a breath and think about
the other drugs we've talked about in this series.
When we look at this as a whole, this is a snapshot.
For people who are good at making clots,
we have these 3 classes or families.
They're in the green boxes: anticoagulants,
antiplatelets, and thrombolytics.
Now, next, we have how the mechanism of
action of each one of these medications,
and each of these medications are
covered in our video series.
But look down at the bottom.
There's 2 giant drops of blood.
We put those there to remind you that any
person taking any 1 of these 3 classes,
categories, or families, is at
an increased risk for bleeding.
That's the major takeaway point.