Shock Syndromes II

Which Anticoagulant

Reversal Agent

Dose

Warfarin with elevated INR

4F-PCC

INR 2 to < 4: 25 units/kg (max 2500

units)

INR 4–6: 35 units/kg (max 3500 units)

INR > 6: 50 units/kg (max 5000 units)

Dabigatran within 3–5 expected half-lives

Idarucizumab

5 g IV push once

Limited data to repeat 5 g

Factor Xa inhibitor within 3–5 expected half-lives

Agent

Last Dose

Andexanet alfa

Low dose: 400-mg bolus at a target rate

of 30 mg/min, 4 mg/min for 120 min

High dose: 800-mg bolus at a target rate

of 30 mg/min and 8 mg/min for 120 min

If time from last dose not known, use

appropriate dose if consumed within 8 hr

Rivaroxaban

≤ 10 mg: Low dose

> 10 mg within 8 hr: High dose

> 10 mg after ≥ 8 hr: Low dose

Apixaban

≤ 5 mg: Low dose

> 5 mg within 8 hr: High dose

> 5 mg after ≥ 8 hr: low dose

Edoxaban

Enoxaparin

High dose at any time

Off-label

Which Anticoagulant

Reversal Agent

Dose

Direct and indirect anti-Xa inhibitors

4F-PCC

aPCC

Off-label

25–50 units/kg

IV = intravenous(ly).

Information from: Sarode R, Milling TJ, Refaai MA, et al. Efficacy and safety of 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting

with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation 2013;128:1234-43; Pollack CV, Reilly PA, Eikelboom J, et al. Idarucizumab for

dabigatran reversal. N Engl J Med 2015;373:511-20; and Connolly SJ, Milling TJ, Eikelboom JW, et al. Andexanet alfa for acute major bleeding associated with factor

Xa inhibitors. N Engl J Med 2016;365:1131-41.

Controversies remain regarding the impact of antiplatelet agents on traumatic bleeding.

for spontaneous intracranial hemorrhage in patients receiving antiplatelet therapy for at least 7 days

prior.

Odds of death were higher in the platelet transfusion group at 3 months than in placebo (adjusted

OR 2.05; 95% CI, 1.18–3.56; p=0.0114), suggesting platelet transfusions are inferior to standard of

care in non-operative patients.

Study limitations include the lack of platelet function tests, inability to ensure medication adherence

before the event, exclusion of surgical patients, and predominant use (greater than 90%) of aspirin

as the antiplatelet agent.

PATCH trial findings are specific to spontaneous intracranial hemorrhage in nonsurgical patients

and may not directly apply to trauma or other settings. Platelet transfusion practices for traumatic

hemorrhage require further randomized controlled trials.

The 2019 European guidelines for managing traumatic bleeding recommend platelet transfusions in

patients who have been treated with antiplatelet agents in the following scenarios:

Continued bleeding with documented platelet dysfunction (grade 2C)

Intracranial hemorrhage undergoing surgery (grade 2B)