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Abstract

An algorithm helps reverse anticoagulation for intracranial hemorrhageFigure: An Algorithm for Reversing Anticoagulation for Intracranial HemorrhageA 65-year-old man with a history of hypertension, diabetes mellitus, and atrial fibrillation presented with a posterior scalp hematoma and altered mental status after a mechanical fall. The patient's family reported that he was taking apixaban, and his last dose had been four hours before arrival. A physical examination revealed a GCS of 13, a blood pressure of 175/99 mm Hg, and asymmetric pupils. The patient was taken to CT, where head imaging revealed a left-sided subdural hematoma with a midline shift and developing uncal herniation. A nicardipine infusion was initiated and the head of the bed was elevated. Andexanet alfa was not available, so an infusion of 4-factor prothrombin complex concentrate was initiated. The patient was taken emergently to the operating room by neurosurgery for a craniotomy and hematoma evacuation. Discontinue Anticoagulation Patients may require blood pressure control including antihypertensive infusions (goal SBP <140). Avoid reversal for intracranial hemorrhage associated with cerebral venous thrombosis. Use cautiously in patients with concomitant life-threatening ischemia, thrombosis, or severe DIC. Vitamin K Antagonists (Ex. Warfarin) Initial Dose: A fixed dose of 4F-PCC 1500 to 2000 units can be given as an initial dose with repeat dosing based on INR measurement 15 minutes after completion of the infusion. Follow local institution guidelines if available. Monitoring and Repeat Dosing: Give vitamin K if the INR is ≥1.4 at 12 hours (Chest. 2008;133[6 Suppl]:160S.) Consider repeat PCC dosing based on INR, though with increased DIC and thrombotic risk, it is recommended to correct further with FFP if INR remains ≥1.4. (J Thromb Haemost. 2008;6[4]:622; https://bit.ly/3ZDvpdU.) Direct Factor Xa Inhibitors (Ex. Rivaroxaban, Apixaban) Activated charcoal may be effective for up to six hours for apixaban (https://bit.ly/41PvXPJ) and eight hours for rivaroxaban (https://bit.ly/3L2mQFm). Andexanet Alfa Regimens (Stroke. 2021;52[6]:2096; https://bit.ly/3STy01c; J Am Coll Emerg Physicians Open. 2022;3[2]:e12655; https://bit.ly/3IYilZH.) Low-dose: rivaroxaban <10 mg, apixaban <5 mg, edoxaban <30 mg or eight or more hours since last dose High-dose: If greater than the thresholds above or dose/timing unknown Pentasaccharides (Ex. Fondaparinux) Use high-dose Andexanet alfa regimen (Nat Med. 2013;19[4]:446). Direct Thrombin Inhibitors (Ex. Dabigatran) Monitoring and Repeat Dosing: If the patient has ongoing significant bleeding after treatment, consider redosing idarucizumab or hemodialysis. Alternative Regimens: If idarucizumab is not available, aPCC (50-80 units/kg), 4F-PCC, or 3F-PCC (50 units/kg) can be used in order of preference. Unfractionated Heparin Dosing: Heparin units are based on estimated active agent (half-life 1-2 hours). Protamine sulfate 1 mg/100 units IV, maximum dose 50 mg Alternatively, give fixed dose of 25 to 50 mg. Monitoring and Repeat Dosing: If aPTT is persistently elevated, repeat 0.5 mg/100 units. Low-Molecular Weight Heparin (Clin Pharmacokinet. 2003;42[12]:1043.) Reversal is not indicated if more than three to five half-lives have passed since administration: Enoxaparin mean half-life: Four to five hours Dalteparin mean half-life: 2.8 hours Nadroparin mean half-life: 3.7 hours If bleeding persists or the patient has or renal insufficiency, repeat dose 0.5 mg/1 mg enoxaparin or 0.5 mg/100 anti-Xa units. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].