Anticoagulant Reversal in Severe Trauma

Educational Objectives

The goal of this program is to improve management of severe bleeding in trauma patients on anticoagulation. After hearing and assimilating this program, the clinician will be better able to:

1. Manage severe bleeding in trauma patients taking anticoagulant and antiplatelet medications.

Summary

Western Trauma Association (WTA) algorithm for management of patients on anticoagulation in the trauma setting: after assessing and addressing life-threatening bleeding, obtain history of anticoagulant use; laboratory tests can then be done; if the anticoagulant is unknown, use prothrombin complex concentrate (PCC); directed reversal strategy can be used if anticoagulant is known; after workup and interventions, the patient should be assessed for ongoing bleeding; traumatic coagulopathy, acidosis, and hypothermia should be avoided or corrected; if bleeding persists, repeat interventions or try alternative strategies

Warfarin: a competitive inhibitor of vitamin K on coagulation factors II, VII, IX, and X; frequent monitoring via international normalized ratio (INR) is done because warfarin interacts with several medications and foods; management of less severe injuries is guided by INR at presentation and bleeding control; for life-threatening injuries, immediate reversal is needed; traditionally, 2 or 3 units of fresh frozen plasma (FFP) were given, but PCC is now preferred; because the effects of PCC and FFP last for 6 to 8 hr, giving vitamin K when initiating reversal allows for the creation of new vitamin K-dependent factors by the time effects fade; PCC does not require thawing, reverses the warfarin effect immediately, has 25 times the concentration factors of FFP and with significantly less volume, is better tolerated in renal and cardiac failure, is more likely than FFP to obtain an INR <1.4 within 24 hr, does not require blood type matching, and has fewer transfusion reactions and minimal complications; the speaker uses an INR-based dose of PCC and gives a dose of vitamin K at the initiation of reversal

Direct oral anticoagulants (DOACs): apixaban (Eliquis) and rivaroxaban (Xarelto) are the most commonly used factor Xa inhibitors; their effect is monitored by checking anti-factor Xa levels; prothrombin time (PT) and partial thromboplastin time (PTT) are not reliable indicators of their effect; they require less monitoring, have fewer drug interactions, need less dose adjustment, have a predictable anticoagulation effect, and have less severe bleeding complications than warfarin; warfarin is still preferred for patients with mechanical valves, during pregnancy, and for children; PCC is commonly used to reverse factor Xa inhibitors; andexanet alfa is a directed reversal agent for apixaban and rivaroxaban, but its high cost has limited uptake; ciraparantag, which is being investigated, is a synthetic molecule that binds DOACs and enoxaparin; for reversal, the speaker uses 2000 units of PCC; dabigatran (Pradaxa) is a competitive direct thrombin inhibitor; most tests used to monitor its effect are not reliable; reversal is achieved with idarucizumab (Praxbind), given as 2 consecutive doses over 10 min, ideally ≤10 min of admission; if not available, a fixed dose of PCC is given

Antiplatelet medications: acetylsalicylic acid and clopidogrel (Plavix) are commonly used in coronary artery disease, stroke, and stent thrombosis; specific testing is unreliable in acute trauma, and no direct reversal agent exists; because many agents irreversibly inhibit platelet function, effects last for 7 to 10 days; platelet transfusion has limited benefits and may worsen outcomes; the Society of Critical Care Medicine (SCCM) recommends it only in the setting of an intervention; desmopressin (DDAVP) enhances platelet function and aggregation and improves bleeding time and coagulation; the SCCM recommends one dose of DDAVP for patients with intracranial hemorrhage on antiplatelet medication; studies are looking into the utility of fibrinogen and tranexamic acid; the speaker gives a weight-based dose of DDAVP to patients on antiplatelet medication and reserves transfusion for patients who need invasive interventions or have thrombocytopenia

Restarting anticoagulation: if the bleeding source has been identified and controlled and anticoagulation is needed, restarting appears to be safe from day 14 to 30

Readings

Chai-Adisaksopha C, Hillis C, Siegal DM, et al. Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal. A systematic review and meta-analysis. Thromb Haemost. 2016;116(5):879-890. doi:10.1160/TH16-04-0266; Shahzad F, Ahmed U, Muhammad A, et al. Safety and efficacy of desmopressin (DDAVP) in preventing hematoma expansion in intracranial hemorrhage associated with antiplatelet drugs use: A systematic review and metaanalysis. Brain Behav. 2024;14(5):e3540. doi:10.1002/brb3.3540; van der Horst SFB, Martens ESL, den Exter PL, et al. Idarucizumab for dabigatran reversal: A systematic review and meta-analysis of indications and outcomes. Thromb Res. 2023;228:21-32. doi:10.1016/j.thromres.2023.05.020.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Patel was recorded at Mattox Vegas Trauma, Critical Care & Acute Care Surgery 2023, held March 27-29, 2023, in Las Vegas, NV, and presented by the Trauma and Critical Care Foundation. For information about upcoming CME activities from this presenter, please visit https://www.trauma-criticalcare.com. Audio Digest thanks the speakers and the Trauma and Critical Care Foundation for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

GS712001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.