Medication Reversal Warfarin Investigation : INR Reversal - 10 mg IV vitamin K over 30 minutes * plus* either PCC or fresh frozen plasma - PCC is front line: Usually fixed dose PCC (1500 Units), repeat INR in 30 minutes CNS bleed: consider traditional dosing INR 2 - 4: 25 units/kg (max 2500 units) INR 4 - 6: 35 units/kg (max 3500 units) INR >6: 50 units/kg (max 5000 units) - Alternative: four units fresh frozen plasma Dabigatran Investigation : PTT (ideal = thrombin time) Reversal : Idarucizumab 5 g - If ingested in <2 hours may consider activated charcoal 50g Riveroxaban Apixaban Edoxaban Investigation : INR (ideal = anti - Xa level, using any assay) Reversal : 4 - factor PCC - Regimens vary: Fixed dose of 2000 units often recommended. CNS bleed: consider 50 units/kg (max 5000 units) - If ingested in <2 hours may consider activated charcoal 50g - Consider 10 mg IV vitamin K to exclude vitamin K deficiency (if INR elevated) Thrombolysis (tPA) Investigation : INR, PTT, fibrinogen Reversal : Cocktails vary, reasonable starting place might be: - Aggressive fibrinogen replacement (e.g. 10 U cryoprecipitate) - 2 Units fresh frozen plasma - Tranexamic acid (1 gram bolus, then 1 gram over 8 hr) Heparin Investigation : PTT (ideal = anti - Xa level) Reversal: Protamine (complex dosing, see above) Anti - platelet agents Investigation : Platelet function assays (if available) Reversal - Desmopressin (DDAVP) 0.3 ug/kg infuse over 20 - 30 minutes - May consider addition of tranexamic acid ? - Evidence generally doesn’t support platelet transfusion Rapid guide to anticoagulant reversal in hemorrhage - The Internet Book of Critical Care, by @PulmCrit