Anticoagulation Reversal From EM Cases – Never Push IV Vitamin K – See Vit K Resource From Hopkins

This post contains a link to the section on Anticoagulation Reversal from the EM Cases Quick Hits*, September 2019.

*Helman, A. Swaminathan, A. Austin, E. Long, B. Rosenberg, H. Ho, M. Cheskes, S. EM Quick Hits 8 – Lemierre’s Disease, Clonidine Toxicity, Routine Coag Panel, Anticoagulation Reversal, Mechanical CPR. September, 2019. Accessed 9-30-2019.

The portion of the podcast on anticoagulation reversal is from 17:22 to 24:00.

Here are the show notes:

Anticoagulation Reversal: Review of CJEM’s ‘Just the Facts’ series
  • Consider reversal of anticoagulation if there is a life-threatening or major bleed.

Reversal by anticoagulant:

  • Warfarin: Vitamin K inhibitor
    • An INR should guide reversal, unless there is an immediate life-threat requiring immediate reversal. PCC (Octaplex in Canada) combined with IV vitamin K*  are the agents of choice.
    • [Never push IV Vitamin K*]
    • Make sure to repeat the INR 30 minutes and 6 hours post PCC dose.

*Appendix B: Phytadione (Vitamin K) Dosing Guidelines [PDF] 9-14-2009 from Johns Hopkins Medicine.

  • Dabigatran: Factor IIa inhibitor
    • If they have a normal aPTT there is likely not a large burden of dabigatran. If you are able to get a normal Thrombin time, this excludes dabigatran.
    • For reversal, PCC is the main stay.
    • Idarucizumab (Praxbind) is an agent available currently for reversal however it has not been studied compared to a control group. Its use is controversial but not unreasonable.
  • Apixaban, Rivaroxaban, Edoxaban: Factor Xa inhibitors
    • The only available agent for reversal in Canada is PCC. Studies with PCC do not have control groups.
    • In the US Andexanet Alpha may reverse blood peramers, however it is very expensive, has a high risk of thrombosis and has not been shown to improve patient oriented outcomes. Therefore it is not currently recommended by our experts.

References from the show notes

  1. Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e44S-e88S.
  2. Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol. 2019;94(6):697-709.
  3. Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017;70(24):3042-3067.



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