Medication assignment!

Daytonite, BSN, RN · Apr 6, 2006

http://www.drugs.com/pdr/heparin_sodium_injection.html - professional provider information on heparin - states "bleeding is the chief sign of heparin overdosage. nosebleeds, blood in urine, or tarry stools may be noted as the first sign of bleeding. easy bruising or petechial formations may precede frank bleeding." treatment is "neutralization of heparin effect - when clinical circumstances (bleeding) require reversal of heparinization, protamine sulfate (1% solution) by slow infusion will neutralize heparin sodium. no more than 50 mg should be administered, very slowly, in any 10-minute period. each mg of protamine sulfate neutralizes approximately 100 usp heparin units. the amount of protamine required decreases over time as heparin is metabolized. although the metabolism of heparin is complex, it may, for the purpose of choosing a protamine dose, be assumed to have a half-life of about ½ hour after intravenous injection.

administration of protamine sulfate can cause severe hypotensive and anaphylactoid reactions. because fatal reactions, often resembling anaphylaxis, have been reported, the drug should be given only when resuscitation techniques and treatment of anaphylactoid shock are readily available."

a check of the interactions between heparin and aspirin (cardiprin) at this site

http://www.drugstore.com/pharmacy/drugchecker/interactions.asp?drugs=heparin+sodium+i.v.%7c110125%3baspirin%7c105844&patientdrugs=&x=81&y=9 indicate (after all the reading) that the symptoms would be "unusual or excessive bruising, wounds that will not heal, blood in your stool (dark or black stools or bright red blood in your stools), blood in your urine, vomiting blood, or a nose bleed that will not stop." this is essentially what the symptoms of the overdosage of heparin are.

you also want to give consideration to the patient's blood pressure, especially if it is elevated and there is difficulty controlling it, and whether or not there may be liver disease present as this will aggravate any bleeding tendencies. i'll let you look up the pathophysiology on the liver disease and bleeding .

cchange · Apr 8, 2006

Hi,

Thanks so much for your suggestions! That's pretty much what I had figured from looking at the drugs. Since then our lecturer has had so many questions from students she has given us a big hint that we should see the petechiae as a 'rash' which has confused us again as nowhere is petechiae referred to as a rash, ie an allergy to a drug and I had assumed it was caused by the bleeding (ie heparin and cardiprin). This leads me to think she wants us to suggest he's allergic to the penicillin???!

Daytonite, BSN, RN · Apr 8, 2006

thanks so much for your suggestions! that's pretty much what i had figured from looking at the drugs. since then our lecturer has had so many questions from students she has given us a big hint that we should see the petechiae as a 'rash' which has confused us again as nowhere is petechiae referred to as a rash, ie an allergy to a drug and i had assumed it was caused by the bleeding (ie heparin and cardiprin). this leads me to think she wants us to suggest he's allergic to the penicillin???!

hmmm. . .my first guess would be the amoxil. my experience with patients who develop an allergy to penicillin is that they get a rash over the trunk and chest first, so i would say yes to the amoxil. yet, many times those rashes are also accompanied by some swelling and pruritis, or itching, since the allergic response causes a release of histamine which causes this. if it were me, i would look at the physiology of the allergic response as evidence that petechiae doesn't fit those symptoms. but, then, this is for your grade, not mine. i looked at the pdr information on drugs.com and it lists erythematous maculopapular rashes as an adverse effect (http://www.drugs.com/pdr/amoxil_capsules.html) for amoxil (amoxicillin). however, the drug information for metoprolol (betaloc) also lists a rash as an allergic response.

http://www.drugs.com/pdr/metoprolol_succinate.html

is there any chance your instructor might be throwing out a red herring just to muddy up the water here? the reason i ask is because petechiae is a pretty specific symptom and i don't know that i would want to confuse it with an allergic rash.

Daytonite, BSN, RN · Apr 8, 2006

Well, I'm going to change my thinking after looking up a few things.

I just looked up the definition of petechiae in my copy of Taber's Cyclopedic Medical Dictionary (18th ed.). Here's what it says: "Small, purplish, hemorrhagic spots on the skin that appear in certain severe fevers and are indicative of great prostration, as in typhus. They may be due to an abnormality of the blood-clotting mechanism. This term is also applied to similar spots occurring on the mucous membranes or serous surfaces." Let me also say that I have seen this phenomenon and the skin is flat and these spots are usually very, very tiny. Now, under rash the dictionary lists a hemorrhagic rash and ecchymotic rash as "a rash consisting chiefly of hemorrhages or ecchymoses."

My Textbook of Physical Diagnosis: History and Examination by Mark H. Swartz lists something very interesting about petechiae. That is that they are nonblanching to tactile pressure. That makes sense. Also, all the pictures (and there are a number of them in the book) are of petechiae in the buccal cavity or palate. That leads me to think that petechiae on the chest alone might not be a "normal" site for them. I'm thinking that stands to reason since the mucus membranes are going to be rich in capillaries as opposed to the skin of the chest.

So, if this is an allergic rash, what's causing it? Who knows? One point of information in the scenario is that this man fell into a river which at first seems like an unimportant piece of information. A maculopapular rash is one of the symptoms of typhus, but there are other symptoms as well that this man is lacking.

When you get the final answer to this from your instructor, please post it here, won't you? Now, I want to know the answer.

cchange · Apr 10, 2006

Hi Daytonite and thanks again for your help!

Our lecturer definately wants us to see it as a rash and to look at the time line of the drugs given so I take that to mean it's more likely to be the Amoxil since it was administered the night before as opposed to the Betaloc which he has been on for longer.....it's a confusing one as all the definitions I've seen of petechiae are similar to yours, i.e. not really a rash, more like haemorrhaging in small spots. I'm not sure how we're supposed to make the connection in our assignment......but I'll have to find a way!

It's not due until next week so I won't know for a bit but I'll definately let you know. A nursing friend of mine who briefly looked at the question (via email from her nursing job on a cruise ship in the Caribbean!) immediately suspected he had an allergic reaction to the Amoxil and suggested Azithromycin instead....so perhaps it is something which is seen in patients.

Hmmm. At least it's making us think!