Approach to the critical patient
›First 5 minutes workflow
›Cardiac and pulse oximetry monitoring
›Two large bore IVs or IO if needed
›Massive transfusion protocol activation if unstable bleeding
›Type specific blood if immediate need
Anticoagulant holding and reversal decision
›Reversal decision logic
›Immediate reversal for life threatening bleeding
›Immediate reversal for urgent surgery with high bleeding risk
›No routine reversal for isolated lab abnormality without bleeding unless very high INR or procedure planned
›Warfarin management
›Hold warfarin
›Vitamin K PO 1 mg to 2.5 mg for elevated INR without bleeding local protocol dependent
›Vitamin K IV 5 mg to 10 mg for major bleeding or urgent procedure
›4 factor PCC for major bleeding
›Dose per product and INR local protocol dependent
›Fresh frozen plasma if PCC unavailable
Factor Xa inhibitor reversal
›Apixaban and rivaroxaban reversal
›Hold agent
›Andexanet alfa for life threatening bleeding when available local protocol dependent
›4 factor PCC 50 units per kg IV for life threatening bleeding when andexanet unavailable local protocol dependent
›Activated charcoal if ingestion within 2 hours and airway protected
›Dabigatran reversal
›Hold agent
›Idarucizumab 5 g IV total
›Two consecutive 2.5 g doses
›Hemodialysis for severe bleeding with renal failure when needed
›Activated charcoal if ingestion within 2 hours and airway protected
Heparin and low molecular weight heparin reversal
›Heparin reversal
›Stop infusion
›Protamine dosing
›1 mg protamine per 100 units heparin given in prior 2 to 3 hours
›Maximum single dose 50 mg
›Enoxaparin reversal
›Protamine 1 mg per 1 mg enoxaparin if within 8 hours
›Protamine 0.5 mg per 1 mg enoxaparin if 8 to 12 hours
›Blood product strategy
›PRBC transfusion threshold individualized
›Platelets for antiplatelet associated life threatening bleeding or thrombocytopenia per cause local protocol dependent
›Fibrinogen replacement
›Cryoprecipitate or fibrinogen concentrate to target at least 1.5 g/L in active bleeding
Consults and reassessment loop
›Consultation plan
›Hematology for complex coagulopathy or inhibitors
›Gastroenterology for suspected GI bleeding
›Neurosurgery for intracranial hemorrhage
›Reassessment loop
›Repeat vitals every 15 to 30 minutes until stable
›Repeat hemoglobin at 4 to 6 hours or sooner if unstable
›Repeat INR or drug relevant test after reversal when applicable