FOR BLEEDING PATIENTS ON ORAL ANTICOAGULANTS, EARLY CONSULT WITH THE MTS EMERGENCY, TRAUMA AND HAEMATOLOGY STAFF VIA ARV IS ADVISED TO ASSIST IN DIRECTING PATIENT CARE AND TO FACILITATE EARLY RETRIEVAL.
Complete primary survey and identify likely source and level of bleeding
Identify which OAC patient is taking and time of last dose
Perform baseline laboratory assessment: FBC, routine coagulation studies, INR if on Warfarin and where available specific drug levels. Creatinine should be measured to identify presence of any pre-existing renal or hepatic impairment
Organise blood group and hold, antibody screen
Local haemostatic measures
Consider withholding next dose of anticoagulant or discontinue treatment as appropriate (thrombosis vs bleeding risk)
Consider the risk of worsening bleeding. Early reversal or replacement of factors may prevent worsening of bleeding
Clinically significant bleeding (reduction in Hb >20g/L, transfusion of >2 units of red cells)
Administer oral charcoal if OAC ingested<2 hr prior and discontinue OAC
Apply local haemorrhage control techniques & consider surgical or radiological intervention to identify and treat bleeding source
Maintain adequate hydration to aid in drug clearance
Transfusion of red cells should be administered as clinically appropriate. Platelet transfusion should be considered in patients on concurrent anti platelet therapy or with significant thrombocytopenia (platelet <50 x 109/L). Use FFP if concerned about dilutional coagulopathy.17
Contact retrieval services for haematology advice and to initiate retrieval & transfer to a MTC
Continuously monitor haemodynamic status
Consider administration of Vitamin K if patient is on Warfarin
Life threatening bleeding (bleeding in critical area or organ (intraocular, intracranial, intraspinal, compartment syndrome, retroperitoneal or pericardial), hypotension not responding to resuscitation
Institute above clinical measures
Consider use of one of the following agents:
*Prothrombinex – VF 25-50 units/kg IV
*FEIBA 50 IU/kg
Tranexamic acid 15-30 mg/kg IV +/- infusion for mucosal bleeds
Vitamin K 5-10mg slow IV injection for full reversal in 12-24 hours (only if on Warfarin)
Consider dialysis for Dabigatran where an excessively prolonged APTT >80s or dabigatran level >500ng/mL and/or impaired renal function. Dialysis can remove approximately 60% of the drug over 3-4 hours.
In Dabigatran, consider Idarucizumab administration after haematology approval. The complete dose of 5g should be given as two consecutive IV infusions over 5-10 minutes each no more than 15 minutes apart).
Recombinant factor VIIa (Novoseven) IV bolus 50mcg/kg may be trialled if critical bleeding from Rivaroxaban and Apixaban. If ongoing bleeding, discuss with haematology. Patient approval should be obtained as per local procedure for its use in non-haemophiliac patients who have failed to respond to conventional therapy.
Pro-haemostatic agents are unlikely to improve outcome in patients on Rivaroxaban with a normal PT.
*This is an off license use of FEIBA and Prothrombinex-VF and the risk of thrombotic complications with these agents when used for this indication is unclear. Their use is supported by laboratory data but clinical evidence supporting the improvement in patient outcomes is lacking.
Taken from Tran, H. Joseph, J. Young, L. McRae, S. Curnow, J, Nandurkar, H. Wood, P. and McLintock, C. New oral anticoagulants: a practical guide on prescription laboratory testing and peri-procedural / bleeding management. Int Med J. 2014;(44):525-36