Anticoagulant related Intracranial Bleeds
Unlock the secrets to effective Intracranial Hemorrhage (ICH) management with this comprehensive guide. From essential stat labs for all cases to targeted interventions for IV TPA-related ICH, Warfarin-related ICH, and bleeding from anticoagulants like Direct Thrombin Inhibitors and Factor Xa Inhibitors.
All cases of ICH send stat labs : Platelets, PT, INR, PTT, Fibrinogen
- IV TPA related ICH
Cryoprecipitate 10 Units, check Fibrinogen levels 30 minutes later:
If Fibrinogen 50-100mg/dl give 10 Units Cryoprecipitate
If Fibrinogen <50 give 20 Units Cryoprecipitate
Platelets 6 Units of random donor platelets or 1 unit of single donor platelets/ pheresis platelets
Other options if bleed within 4 hours of TPA : Tranexamic acid 1gm IV x 1 OR Aminocaproic acid 5 gm IV stat
- Warfarin related Intracranial Hemorrhage
Vitamin K 5 mg IV x 1
Prothrombin Complex Concentrate (PCC)
INR 1.6-3.9 PCC 25 U/kg (for purposes of calculation max body weight 100kg)
INR 4.0-6.0 PCC 35 U/kg
INR >6.0 PCC 50 U/kg
Repeat INR after 30 min, if >1.5 give 10U/kg PCC
Alternative to PCC: FFP 2-4 units
- ICH from Direct Thrombin Inhibitors (Dabigatran/Pradaxa, Bivalirudin/Angiomax)
Idarucizumab 2.5 gm IV , repeat in 15 minutes (each dose over 10 min)
If Idarucizumab is not available use PCC 25 U/kg
Maintain diuresis
Activated charcoal if last dose within 2 hours
- ICH from Factor X a Inhibitors
(Apixaban/Eliquis, Rivaroxaban/Xarelto, Betrixaban/Bevyxxa, Endoxaban/Savaysa, Fondaparinux/Arixtra)
PCC 25 U/kg
Maintain diuresis
Activated charcoal if last dose within 2 hours
- ICH from Unfractionated Heparin
Protamine 1mg for every 100 U Heparin given in last 2 hours IV, followed by stat PTT
If PTT > 43 , repeat Protamine 10mg until PTT<43 or Protamine maxed out at 50mg
Screen for Heparin Induced Thrombocytopenia: Check Heparin Induced Platelet Antibodies.
- ICH from Low Molecular Weight Heparin (Dalteparin, Enoxaparin, Tinzaparin)
If last dose less than 8 hours back, give 1mg Protamine per 1mg of LMWH. Maximum dose 50 mg
If last dose was more than 8h back, give 0.5mg Protamine per 1 mg of LMWH. Max 50 mg
