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EDUCATION IN THE MANAGEMENT OF BLEEDING

A practical, evidence-based guide for front-line physicians on how to Treat the Bleed

How do I manage a patient with a life-threatening bleed on warfarin?

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General approach as follows:

  1. Withdrawal of anticoagulants and supportive care
    • Stop anti-coagulants and determine time of last dose
    • Stop anti-platelet agents
    • Laboratory investigations: CBC, INR/aPTT/fibrinogen, group & screen
    • Consider blood transfusion - if the patient requires ≥ 3 units of RBCs in 1 hour, consider massive haemorrhage protocol activation
      • Uncrossmatched blood sent stat if group & screen pending (~10 min) – O negative for women age ≤45, O positive for everyone else
  2. Reversal of warfarin - Both fast and slow reversal required:
    • Fast reversal: Administer Prothrombin Complex Concentrates (PCCs) – dosed based on INR ± Weight (see chart below)
      • If INR is unknown administer 2000 IU
      • Do not wait for INR results during life-threatening bleeding
    • Slow reversal: Administer Vitamin K – 10 mg IV
    • Frozen plasma transfusion despite being common is not appropriate standard of care, unless PCCs unavailable or history of heparin induced thrombocytopenia (HIT)
  3. Adjunct treatments to stop the bleed
    • Tranexamic Acid - consider up to 2 g IV total
      • Not studied specifically in bleeding patients on warfarin
      • Consult interventional radiology or surgery

Dosing based on NAC recommendations:

INR Based Dosing:

 PCC dose if INR <3PCC dose if INR 3-5PCC dose if INR > 5
 Dose 1000 IU ( 40 mL) 2000 IU (80 mL) 3000 IU (120 mL)

 

Weight plus INR based dosing:

Weight (kg)PCC dose if INR 2-2.9
(20 units/kg)
PCC dose if INR 3-6
(30 units/kg)
PCC dose if INR > 6
(40 units/kg)
35-37 500 IU ( 20 mL) 1000 IU ( 40 mL) 1500 IU (60 mL)
38-41 1000 IU ( 40 mL) 1000 IU ( 40 mL) 1500 IU (60 mL)
42-43 1000 IU ( 40 mL) 1500 IU (60 mL) 1500 IU (60 mL)
44-56 1000 IU ( 40 mL) 1500 IU (60 mL) 2000 IU (80 mL)
57-58 1000 IU ( 40 mL) 1500 IU (60 mL) 2500 IU (100 mL)
59-62 1000 IU ( 40 mL) 2000 IU (80 mL) 2500 IU (100 mL)
63-68 1500 IU (60 mL) 2000 IU (80 mL) 2500 IU (100 mL)
69-75 1500 IU (60 mL) 2000 IU (80 mL) 3000 IU (120 mL)
76-87 1500 IU (60 mL) 2500 IU (100 mL) 3000 IU (120 mL)
88-91 2000 IU (80 mL) 2500 IU (100 mL) 3000 IU (120 mL)
92-112 2000 IU (80 mL) 3000 IU (120 mL) 3000 IU (120 mL)
113-136 2500 IU (100 mL) 3000 IU (120 mL) 3000 IU (120 mL)
137 or greater 3000 IU (120 mL) 3000 IU (120 mL) 3000 IU (120 mL)
Asset 2

A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding