Level 1 of 6Core
Bleeding disorders and anticoagulation reversal
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Ask which drug, and the exact clock time of the last dose, verified against the packet or anticoagulation record — patients frequently do not know the name of the drug they take: warfarin, unfractionated heparin, LMWH, fondaparinux, dabigatran, rivaroxaban, apixaban, edoxaban, aspirin, clopidogrel, prasugrel or ticagrelor.
- Is this major haemorrhage (ISTH)? Fatal bleeding; or symptomatic bleeding into a critical site (intracranial, intraspinal, intraocular, retroperitoneal, intra-articular, pericardial, or intramuscular with compartment syndrome); or a haemoglobin fall of 20 g/L or more; or needing two or more units of red cells — and shock, or bleeding that will clearly need products, counts as major regardless of numbers.
- The site of bleeding names the mechanism: mucocutaneous bleeding (petechiae, bruising, gingival bleeding, epistaxis, GI/GU bleeding, heavy menstrual loss) = platelet defect or von Willebrand disease; joints, deep muscle and retroperitoneum = coagulation factor deficiency or anticoagulant excess; oozing from every venepuncture site in a shocked septic patient = DIC until proved otherwise.
- Immediate danger signs: bleeding into the mouth, tongue, floor of mouth or neck (airway obstruction within minutes); any deterioration in conscious level in an anticoagulated patient; shock; wet purpura (oral blood blisters) or retinal haemorrhage in severe thrombocytopenia; a tense painful limb compartment; bleeding continuing despite adequate mechanical control. Suspect concealed retroperitoneal bleeding with flank or back pain, femoral neuropathy, or unexplained hypotension with a falling haemoglobin.
- Send before any product: FBC with film, PT/INR, aPTT, fibrinogen, D-dimer, renal and liver function, group-and-save or crossmatch. Look at the film before ordering platelets — ask specifically about schistocytes and platelet clumping: low platelets + schistocytes + normal PT, aPTT and fibrinogen = thrombotic microangiopathy, in which platelet transfusion may propagate microthrombi.Not available at your setup — Coagulation (PT/INR).
- A normal PT and aPTT do not exclude a clinically important DOAC level — the time of the last dose and the creatinine are worth more than the coagulation screen; renal impairment prolongs LMWH and every DOAC. Any anticoagulated patient with head injury, headache, vomiting, confusion or an unexplained fall requires CT head even with a normal conscious level — but reversal is not delayed for it when the picture is convincing.Not available at your setup — CT scan, Renal function (creatinine/urea).
Manage now— do this, in order
- Five things proceed in parallel: stop the offending drug; support the circulation while limiting dilution; achieve mechanical control of the bleeding point; give the specific reversal agent and replace what is missing; treat the underlying cause. Reversal in a critical-site bleed begins on clinical grounds — it is not delayed for laboratory confirmation.
- Mechanical control first: firm uninterrupted direct pressure for a full ten minutes; epistaxis — compress the cartilaginous nose 10–15 minutes with the patient leaning forward before packing; bleeding dental socket — gauze soaked in tranexamic acid held for 20 minutes.
- Fluids limit dilution: warmed crystalloid in 250–500 mL boluses in an adult (10–20 mL/kg in a child), reassessing after each, moving early to blood components — do not chase a normal blood pressure with clear fluid. Correct hypothermia, acidosis and hypocalcaemia, each of which impairs coagulation; minimise venepuncture and avoid non-compressible sites such as the subclavian vein.Doctor / Nurse
- Tranexamic acid for most significant bleeding: adults 1 g IV over 10 minutes then 1 g by infusion over 8 hours; children 15 mg/kg IV over 10 minutes (max 1 g) then 2 mg/kg/hour; heavy menstrual bleeding in a known bleeding disorder — 1300 mg orally every 8 hours. Never in upper urinary tract bleeding (clot may obstruct the ureter) and never in DIC (dangerous fibrin deposition).Doctor / Nurse
- Warfarin: major bleeding — phytomenadione (vitamin K₁) 5–10 mg slow IV PLUS four-factor PCC 25–50 units/kg IV, recheck INR at 30 minutes and 6 hours; FFP 15–30 mL/kg only if PCC is unavailable. Minor bleeding — withhold warfarin, vitamin K 1–3 mg IV. High INR without bleeding — below 8 omit doses and recheck daily; above 8 give vitamin K 1–2.5 mg orally or IV (2.5–5 mg orally accepted above 10). With a mechanical valve use the smallest effective dose, as little as 1 mg.Doctor / NurseNot available at your setup — Blood & blood products, Coagulation (PT/INR). If four-factor PCC is unavailable, give fresh frozen plasma 15–30 mL/kg.
- Heparins: UFH — stop the infusion (the short half-life often suffices); protamine sulfate 1 mg IV per 100 units of UFH given in the preceding 2–3 hours, maximum 50 mg, over at least 10 minutes — rapid injection causes hypotension, bradycardia and anaphylaxis. LMWH — protamine 1 mg per 1 mg enoxaparin if given within 8 hours, max 50 mg; reversal is only partial.Doctor / Nurse
- DOACs: dabigatran — idarucizumab 5 g IV as two 2.5 g doses; fallback four-factor PCC 25–50 units/kg, and dabigatran is dialysable; vitamin K is useless. Rivaroxaban, apixaban or edoxaban — andexanet alfa; fallback four-factor PCC 25–50 units/kg. Antiplatelets: stop the drug, desmopressin 0.3 micrograms/kg IV plus tranexamic acid; platelets only for life-threatening bleeding or before urgent surgery — the effect persists 7–9 days.Doctor / NurseNot available at your setup — Blood & blood products. Where idarucizumab or andexanet alfa is unavailable, four-factor PCC 25–50 units/kg is the fallback; dabigatran can also be dialysed.
- Component targets: platelets above 20 × 10⁹/L in most bleeding patients, above 50 × 10⁹/L for serious bleeding such as intracranial haemorrhage; fibrinogen above 0.8–1.0 g/L with cryoprecipitate or fibrinogen concentrate — correct the fibrinogen BEFORE giving FFP for a prolonged PT and aPTT, then re-test; FFP only for prolonged PT AND aPTT WITH bleeding (target below 1.5 × normal); red cells for haemoglobin above 80 g/L. No product for abnormal numbers with no bleeding. Paediatric: FFP 15–20 mL/kg, platelets 10–15 mL/kg, cryoprecipitate 5–10 mL/kg, PCC 25–50 units/kg; vitamin K in a child 250–300 micrograms/kg slow IV, max 10 mg.Doctor / NurseNot available at your setup — Blood & blood products, Coagulation (PT/INR).
- In known haemophilia give factor concentrate FIRST — before imaging and before the examination is complete; in head injury, factor precedes the CT scan. Factor VIII units = weight (kg) × desired rise in % × 0.5; factor IX units = weight (kg) × desired rise in %. In HIT: stop ALL heparin including flushes, never substitute LMWH (antibodies cross-react), never start warfarin alone (venous limb gangrene) — start a non-heparin anticoagulant before confirmatory testing returns.Doctor / Nurse
| Drug | Reversal |
|---|---|
| Warfarin (major bleed) | Vitamin K₁ 5–10 mg slow IV + 4F-PCC 25–50 units/kg (FFP 15–30 mL/kg if no PCC) |
| UFH | Stop infusion; protamine 1 mg / 100 units (last 2–3 h), max 50 mg, over ≥10 min |
| LMWH (enoxaparin) | Protamine 1 mg / 1 mg if within 8 h — partial only |
| Dabigatran | Idarucizumab 5 g IV (2 × 2.5 g); fallback PCC; dialysable |
| Rivaroxaban / apixaban / edoxaban | Andexanet alfa; fallback 4F-PCC 25–50 units/kg |
| Antiplatelets | Stop; desmopressin 0.3 µg/kg IV + TXA; platelets only if life-threatening |
Refer / escalate
Refer or transfer urgently any critical-site bleed (intracranial, intraspinal, intraocular, retroperitoneal, pericardial, airway or compartment), any bleeding you cannot control mechanically, suspected TTP (plasma exchange is time-critical and untreated mortality exceeds 95%), suspected HIT, known haemophilia with any head injury, and any patient needing PCC, idarucizumab, andexanet alfa, factor concentrate, plasma exchange or endoscopic, radiological or surgical control you cannot provide.
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