EM Vivas · Anticoagulated trauma
Anticoagulated trauma — gas and decision viva
Viva on PCC/vit K, idarucizumab, andexanet/PCC, and not waiting for labs.
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Target exams
ACEMFRCEMABEM
Prompt
Warfarin ICH then dabigatran bottle appears. Walk through agent-specific reversal and parallel resus.
Interpretation
Reveal interpretationShowHide
Principle. Life-threatening bleed or ICH on anticoagulation: reverse in parallel with ABC and imaging. Do not wait for perfect labs. [1]
Warfarin. 4F-PCC + vitamin K IV.[1]
Dabigatran. Idarucizumab 5 g IV.[2]
Xa inhibitors. Andexanet if available; otherwise PCC protocol. [5][1]
Trauma adjuncts. Blood products, TXA if indicated, source control; neurosurgery for ICH. [4]
References5ShowHide
- [1]Sarode R, Milling TJ Jr, Refaai MA, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study Circulation, 2013.PMID 23935011
- [2]Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal N Engl J Med, 2015.PMID 26095746
- [3]Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury Lancet, 2001.PMID 11356436
- [4]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [5]Connolly SJ, Milling TJ Jr, Eikelboom JW, et al. Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors N Engl J Med, 2016.PMID 27573206