Anticoagulation

Aka: Anticoagulation, Anticoagulant Reversal, Anticoagulant

1. See Also
   1. Warfarin (Coumadin)
   2. Aspirin
   3. Unfractionated Heparin
   4. Low Molecular Weight Heparin
   5. Thrombolytic
   6. Factor Xa Inhibitor
   7. Antiplatelet Therapy for Vascular Disease
   8. Clotting Cascade
2. Management: Venous condition prevention and treatment
   1. See Anticoagulation in Thromboembolism
   2. See Anticoagulation in Atrial Fibrillation
   3. See Anticoagulation in Surgical Patients
   4. See Valve Replacement and Anticoagulation
   5. Conditions: Venous Thromboembolism
      1. Deep Vein Thrombosis
      2. Pulmonary Embolism
      3. Atrial Fibrillation
      4. Artificial Heart Valve Replacement
   6. Preparations: Agents affecting Clotting Pathway (PTT or INR)
      1. Warfarin (Coumadin)
      2. Unfractionated Heparin
      3. Low Molecular Weight Heparin
      4. Direct Thrombin Inhibitors (e.g. Dabigatran)
      5. Factor Xa Inhibitors (e.g. Rivaroxaban)
   7. Preparations: Acute event in an unstable patient or prevention of complications
      1. Thrombolytic (e.g. t-PA, Streptokinase)
   8. Preparations: Preventing complications from Venous Thromboembolism
      1. Greenfield filter
3. Management: Arterial condition prevention and treatment
   1. See Antiplatelet Therapy for Vascular Disease
   2. Conditions
      1. History of Myocardial Infarction, Angina or coronary stenting (PTCA)
      2. History of Cerebrovascular Accident or Transient Ischemic Attack
      3. Peripheral Arterial Disease (e.g. Claudication)
   3. Preparations: Agents affecting platelet aggregation
      1. Aspirin
      2. Dipyridamole (Persantine) alone or in combination with Aspirin (Aggrenox)
      3. Thienopyridines
         1. Clopidogrel (Plavix)
         2. Prasugrel (Effient)
   4. Preparations: Acute, unstable arterial event
      1. Thrombolytic (e.g. t-PA, Streptokinase)
         1. See High Risk Acute Coronary Syndrome Management
         2. See CVA Thrombolysis
         3. See PE Thrombolysis
      2. Glycoprotein IIB/IIIA Inhibitor
         1. Abciximab (ReoPro)
         2. Tirofiban (Aggrastat)
         3. Eptifibatide (Integrilin)
4. Management: Reversal of Anticoagulation in Bleeding
   1. Precaution
      1. Most reversal agents (PCC, rFVIIa) are thrombogenic and a risk for thromboembolic events
   2. Warfarin and other Vitamin K Antagonists
      1. See Warfarin Reversal
      2. Vitamin K 5-10 mg slowly IV
      3. Factor Replacement
         1. Fresh Frozen Plasma (FFP)
            1. Indicated if PCC unavailable
         2. Prothrombin Complex Concentrate (PCC) - preferred
            1. PCC 4000 IU (typical adult dose, adjust per weight)
   3. Heparin (unfractionated and LMWH)
      1. Stop Heparin infusion
      2. Protamine (only partially reverses LMWH)
         1. See Protamine for details
   4. Direct Thrombin Inhibitors (e.g. Dabigatran)
      1. Stop offending agent (most have short half-life such as 12-14 hours for Dabigatran)
      2. Consider Activated Charcoal if presenting within 2 hours of suspected overdose ingestion
      3. No known antidotes (all recommendations per expert opinion)
      4. Consider Desmopressin (DDAVP) 0.3 mcg/kg
      5. Consider Cryoprecipitate
      6. Consider Prothrombin Complex Concentrate (PCC)
      7. Consider Recombinant activated Clotting Factor VII (rFVIIa) 30-90 mcg/kg
      8. Dialysis is unlikely to be beneficial due to logistics of placing large bore filtered catheters in actively bleeding, coagulopathic patients
   5. Factor Xa Inhibitors (e.g. Rivoroxaban)
      1. Consider Recombinant activated Clotting Factor VII (rFVIIa) 30-90 mcg/kg (expert opinion)
      2. Dialysis is not effective (protein bound)
   6. Aspirin
      1. Platelet Transfusion 1 unit (6 pack)
      2. Consider Desmopressin (DDAVP) 0.3 mcg/kg (expert opinion)
      3. Consider Recombinant activated Clotting Factor VII (rFVIIa) 30-90 mcg/kg (expert opinion)
   7. ADP Inhibitors
      1. Platelet Transfusion 2 units (12 pack)
      2. Consider Desmopressin (DDAVP) 0.3 mcg/kg (expert opinion)
      3. Consider Recombinant activated Clotting Factor VII (rFVIIa) 30-90 mcg/kg (expert opinion)
   8. References
      1. Lex and Orman in Majoewsky (2013) EM:Rap 13(4): 6
      2. Lemkin (2013) Crit Dec Emerg Med 27(4): 2-9