So you have a patient with intracranial bleeding or you have a high pre-ct suspicion of intracranial bleeding and they are taking coumadin, aspirin, or clopidogrel. Should you reverse them? If so, how?
What if the CT is negative? Can you just discharge these patients as soon as they have a negative CT?
In this episode of the EMCrit Podcast, I discuss reversal of anti-coagulant drugs & anti-platelet medications, with particular emphasis on the prothrombin complex concentrates (PCC). I also touch on how to disposition these patients if their initial CT scan is negative.
Reversal Meds
Here are sample guidelines for drug reversal:
Warfarin
Any patient with a history of recent warfarin use, with an INR > 1.5 should immediately receive:
1. Vitamin K 10 mg IVPB over 10 minutes (monitor for hypotension / anaphylaxis) &
2. 50 units/kg of Prothrombin Complex Concentrate (Bebulin or Profilnine) Administer over 20 minutes.
• If PCC unavailable, give 15 cc/kg of FFP
Repeat INR 10 minutes after completion of infusion
Liver failure with known coagulopathy or elevated PT or INR •1.5
1. Vitamin K 10 mg IV over 10 minutes (monitor for hypotension / anaphylaxis) &
2. 50 units/kg of Prothrombin Complex Concentrate (Bebulin or Profilnine) &
3. 2 units of FFP
• If PCC unavailable, give 15 cc/kg of FFP total
Reversal of Platelet Dysfunction: For any patient with antiplatelet (Aspirin, Aggrenox or Clopidogrel) used in last 24 hours administer:
1. dDAVP 0.3 mcg/kg x 1 (20 mcg in 50 cc NS over 15-30 minutes) &
2. 1 donor pack platelets (~6 units)
Review Article of Vitamin K antagonist reversal (Critical Care 2009, 13:209)
Review Article on PCCs (European Journal of Anaesthesiology 2008; 25: 784–789)
CT Negative after Head Trauma while on Anti-coagulants or Anti-plt Meds
One man’s jury-rigged approach:
Minor head trauma (the definition of this in the anticoagulant literature seems to be different than most other head trauma lit, they actually define minor as NO LOC and NO AMNESIA, just a bop to the head)
- Most folks would still say scan these patients once and then observe for 6 hours. A few would say just observe, a very few would say admit for 24 hours. I watch them for 6 hours and then get the CT scan.
Head trauma with LOC, but GCS 15
- definitely scan, definitely observe at least 6 hours, most would say either rescan or admit for 24 hours
Head trauma with LOC, but GCS < 15
- scan, almost certainly admit for 24 hours, probably rescan prior to d/c
Not great literature support for any of this, here are some studies to get you started:
Delayed Posttraumatic Acute Subdural Hematoma in Elderly Patients on Anticoagulation (Neurosurgery 58:851-856, 2006)
Low Dose ASA led to secondary bleeding not seen on initial CT in patients with normal neuro exams (J Trauma 2009 67(3):521)
Podcast: Play in new window | Download (16.8MB) | Embed
Hi, my name is Scott Weingart. 
This is a great talk. It’s funny because I’ve mentioned delayed bleeding in the past to admitting teams and they are usually unaware of this possibility. It definitely makes me think twice about sending these patients home at least without delayed observation in the ED.
Faheem, thanks for commenting. It’s funny that the literature emerges from Neurosurgery and Trauma, and yet they are the services often most reluctant to admit.
We use Factor 7 for head bleeds in patients on warfarin. Should we be using the three-factor PCC along with this? (We have Beriplex (four-factor PCC) at our institution as a study drug, so I’ve seen it in action. I’m looking forward to using it when it’s approved in this country).
Jeremy,
Not a huge fan of factor VIIa for head bleeds as it wears off quickly so the patient is back to anti-coag state and it makes the INR a lie, so you don’t know how effective your reversal. We use 3-factor exclusively and have gotten most of our patient’s reversed. The beriplex would be the ideal, so if you can get access that is what I would use.
Scott
Great talk.
We increasingly use PCC for anticoagulant associated head bleeds with good results. Factor VII would be a good option for patients needing emergent neurosurgical procedures such as an EVD placement. The combination of PCC and Factor VII would amplify the risk of thrombosis in a trauma patient with questionable benefit.
For Anti-platelet bleeds, we rarely transfuse platelets, since the benefit data is still lacking.
Abraham, The problem with factor VIIa for rapid neurosurg procedures is that while the coag tests will normalize; the patient may still be at increased bleeding risk. I think there is no advantage of VIIa over 4-factor PCCs for this use. Do you have evidence for the statement regarding the combination of PCC and VIIa. This combination is only for 3-factor PCCs and the VIIa you should add is to attempt to create something identical to 4-factor PCCs. The benefits are indisputable: 4-factor PCCs are more effective than 3 in the literature. The risks are tough to figure. The 4-factor you are creating is closer to FEIBA than beriplex or similar.
Thank you for all of your work
Scott – I love the PCC’s.
But what are the downsides? Are there big clotting complications? Is it expensive? In other words, should this completely replace FFP for anything – the hemodynamically stable GI Bleed that needs reversal, etc? Why would I use FFP at all anymore?
No downside except cost and the fact that PCC just gives factors and no volume. We wrestle with what the volume should be replaced with? Albumin? Hypertonic saline?