How many units of FFP are recommended as a starting point? Most resources cite 2 U for isolated intracranial bleeds and 4 U for extracranial hemorrages.
fib, cardiac valvular disease, and ventricular dysfunction (significant increases in intravascular volume could result in decompensated heart failure). 7 In addition, large volumes of FFP (10-15 ml/kg) may be required to address serious hemorrhages, making this reversal agent less than ideal in patients suffering from a. FFP administration is limited secondary to the product’s frozen storage, often requiring 15-20 minutes to thaw. As you might expect, risks associated with transfusion include blood-borne infections and allergic reactions. FFP is type specific, with individuals of the AB blood type being universal donors. 5 In addition, providers need to appreciate that vitamin K administration causes a permanent reversal of existing clotting factors, and adequate re-anticoagulation cannot be achieved for nearly 2 weeks.įresh frozen plasma (FFP) – FFP contains all coagulation factors in a non-concentrated form. This reaction is most commonly secondary to the diluent in which the vitamin K is prepared. 6īe aware: anaphylactic reactions to IV vitamin K occur in 3 out of every 10,000 doses. Greater than 24 hours are needed to achieve an effective response, therefore other methods of reversal must be utilized in the interim (see below). 5,6 The time to onset is often 2-6 hours. All patients who are actively bleeding should receive 5-10mg of IV vitamin K by slow infusion. Vitamin K – As mentioned above, vitamin K is an essential cofactor in the synthesis of factors II, VII, IX, X and proteins C and S. Coumadin undergoes hepatic cytochrome metabolism, exhibits 97% plasma protein binding, and is renally eliminated. The duration of action of a single dose of Coumadin ranges from 2-5 days. 3 PT and INR are measures of the extrinsic pathway of the coagulation cascade, and are therefore utilized to monitor Coumadin’s anticoagulation effect. 3Ĭoumadin’s effect generally occurs within 24 hours s/p administration, with peak anticoagulation seen at 72-96 hours. Therapeutic doses of warfarin decrease the total amount of the active form of each vitamin K dependent clotting factor by approximately 30%-50%. 3Ĭoumadin acts through the inhibition of vitamin K epoxide reductase, ultimately limiting the synthesis of Factors II, VII, IX, and X, and the anticoagulant proteins C and S. In the United States, Coumadin is indicated for the prophylaxis and treatment of VTE, PE, thromboembolic complications associated with a.fib or cardiac valve replacement, and for reduction of mortality risk secondary to recurrent MI, embolizations s/p MI and CVAs. Vitamin K Antagonists: Coumadin (Warfarin) Here’s a bit of a visual refresher to reference throughout the discussion: The Clotting Cascade(2) 1 Despite this staggering amount, the aforementioned figure does not reflect adverse bleeding events associated with Direct Thrombin Inhibitors (DTIs) and Factor Xa Inhibitors.Īs EM Docs, it goes without saying that we need to know what to do to address these potentially life-threatening bleeds, so, let’s take a look at the commonly prescribed oral anticoagulants, their mechanisms of action, their pharmacokinetics, and recommendations for their reversal. emergency departments annually for anticoagulant related hemorrages. What should you do? Order FFP? PCC? Factor VIIa? Background You quickly change your focus to reversing the patient’s INR. As the patient’s trauma scan is nearly complete, the med tech calls to inform you of an INR of 8.3. You quickly initiate treatment for suspected increased ICP. HEENT reveals non-reactive pupils: the right 4mm, the left 1mm and a hematoma localized to the right posterior parietal area. ABCs are intact BP 188/99, HR 58, GCS 3T. EMS arrives and reports Afib on initial rhythm strip, peripheral IV access, and the absence of post-intubation sedation.Ĭ-collar is in place. You’re paged to the trauma bay with the report of an incoming elderly male, found down in his home, and intubated in the field secondary to agonal respirations. Author: Erica Simon, DO, MHA (EM Resident Physician, SAUSHEC) // Edited by: Alex Koyfman, MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, & Justin Bright, MD a busy night in the ED.
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