Administration of andexanet alfa for traumatic intracranial hemorrhage in the setting of massive apixaban overdose: A case report.

PURPOSE: Apixaban is a direct-acting oral anticoagulant that selectively inhibits factor Xa. Reversal strategies utilized to treat factor Xa inhibitor-associated bleeding include andexanet alfa, prothrombin complex -concentrate (PCC), and activated PCC (aPCC). The optimal treatment of traumatic intracranial hemorrhage in the setting of an apixaban overdose is unknown. SUMMARY: This case report describes a 69-year-old female who initially presented to an emergency department at a community hospital due to a ground-level fall with traumatic intracranial hemorrhage. The patient reportedly ingested apixaban 275 mg, carvedilol 250 mg, atorvastatin 1,200 mg, and unknown amounts of amlodipine and ethanol. Anti-inhibitor coagulant complex, an aPCC, was administered approximately 3 hours after presentation. Initial thromboelastography performed approximately 4 hours after presentation showed a prolonged reaction time of 16.8 minutes. Ongoing imaging and evidence of coagulopathy prompted repeated aPCC administration to a cumulative dose of approximately 100 U/kg. The patient underwent craniotomy with hematoma evacuation. Postoperative imaging showed expansion of the existing intracranial hemorrhage and new areas of hemorrhage. Andexanet alfa was administered approximately 18 hours after presentation, followed by repeat craniotomy with evacuation of the hematoma. No further expansion of the intracranial hemorrhage was observed, and the reaction time on thromboelastography was normalized at 6.3 minutes. CONCLUSION: This case suggests that andexanet alfa may have a role in the management of traumatic hemorrhage in the setting of an acute massive apixaban overdose. Use of andexanet alfa, PCC, and aPCC in this context requires further research.

Photokeratitis among restaurant workers: A case series.

This case report highlights the challenges associated with the diagnosis and workplace evaluation of occupationally acquired ultraviolet (UV) radiation-induced photokeratitis and associated skin burns in a group of restaurant workers. UV-C spectrum bulbs were inadvertently shipped and installed in insect light traps. Ocular and dermal symptoms were reported in 18 of 85 restaurant employees to varying degrees of severity over a 2-day period. One patient was formally diagnosed with a chemical burn/irritation of the cornea. More severe symptoms were reported by individuals working in close proximity to the lights. This clinical picture can resemble mass chemical or irritant exposure when multiple individuals are affected, and a multidisciplinary approach was required for rapid identification of the source to limit morbidity. Prevention strategies for similar events should be considered which can include limiting hardware compatibility and improving warning labels.