Tasty Morsels of EM 111 – #FRCEM Anticoagulation and reversal

4 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here

(featured image, Gonegonegone on Wikipedia, CC license)

This is a key topic and the key guidelines (I think) are listed here

Outline the agents and their mechanisms?

  • Warfarin
    • vitamin K anatgonist
    • inhibits 2, 7, 9 and 10
  • Dabigatran
    • direct thrombin inhibitor
  • the ‘Xabans’
    • 10a inhibitor (oral enoxapain…)

How should we manage bleeding on warfarin?

  • major bleeding
    • 25-50 units/kg of PCC
    • vitamin K 5mg
    • FFP only if PCC not available
  • non-major bleeding
    • vit k 1-3mg
  • INR>5 no bleeding
    • withhold
  • INR>8 no bleeding
    • withhold
    • 1-5mg vit K orally

How should we manage bleeding on dabigatran?

note the BSH guidance is a few years old so no mention of Idarucizumab. NICE has an evidence summary on it

  • cessation
  • general haemostasis
  • if within 2 hrs consider charcoal
  • they mention dialysis
  • in life threatening bleeding they mention the kitchen sink approach

How should we manage a xaban?

  • please see above and cross fingers…
  • kitchen sink an option

How should we manage major bleeding with lytics?

  • “within 48 hrs’
  • FFP 12ml/kg
  • TXA
  • if fibrinogen low then give some

How should we monitor the new guys?

  • in general you don’t
  • ecarin clotting time suggested for dabigatran
  • most probably affect APTT/PT but these are actually assay specific so check local gudiance
    • the APTT is a crude measure of activity of dabigatran
    • the PT is probably a better measure of rivaroxaban
  • guidance is clear that patients can have totally normal PT/APTT with significant anti coagulation with the new agents


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