A 73-year-old woman is brought to the emergency department due to headache and confusion. Approximately an hour ago, the patient fell while walking down the stairs and hit her head on the banister. She did not lose consciousness but has had worsening headache, nausea, and vomiting. She has also become incoherent. The patient has a history of persistent atrial fibrillation, hypertension, and end-stage renal disease. Her current medications include warfarin, amlodipine, metoprolol, and calcium acetate. She received maintenance hemodialysis earlier today. Blood pressure is 160/100 mm Hg and pulse is 60/min. The patient is lethargic and oriented to person but not to place or time. Cardiopulmonary auscultation reveals clear lung fields and an irregular heart rate. Muscle strength is equal on both sides. CT scan of the head without contrast reveals a right-sided subdural hematoma with mass effect. Hemoglobin is 11.6 g/dL and INR is 2.1. Surgical hematoma evacuation is planned. Which of the following is the best choice for rapid reversal of anticoagulation in this patient?

Question

A 73-year-old woman is brought to the emergency department due to headache and confusion.  Approximately an hour ago, the patient fell while walking down the stairs and hit her head on the banister.  She did not lose consciousness but has had worsening headache, nausea, and vomiting.  She has also become incoherent.  The patient has a history of persistent atrial fibrillation, hypertension, and end-stage renal disease.  Her current medications include warfarin, amlodipine, metoprolol, and calcium acetate.  She received maintenance hemodialysis earlier today.  Blood pressure is 160/100 mm Hg and pulse is 60/min.  The patient is lethargic and oriented to person but not to place or time.  Cardiopulmonary auscultation reveals clear lung fields and an irregular heart rate.  Muscle strength is equal on both sides.  CT scan of the head without contrast reveals a right-sided subdural hematoma with mass effect.  Hemoglobin is 11.6 g/dL and INR is 2.1.  Surgical hematoma evacuation is planned.  Which of the following is the best choice for rapid reversal of anticoagulation in this patient?

Quizplus · Accepted Answer

Explanation: Warfarin is an anticoagulant commonly used in the treatment of atrial fibrillation and venous thromboembolism. Effects arise from the inhibition of vitamin K recycling, which reduces circulating levels of vitamin K-dependent clotting factors II, VII, IX, and X. The major risk of therapy is bleeding-associated complications, particularly intracranial hemorrhage. inhibition of vitamin K Patients on warfarin with intracranial hemorrhage require urgent warfarin reversal to prevent the propagation of hemorrhage; this is accomplished by administering the following: Prothrombin complex concentrate, which contains vitamin K-dependent clotting factors and normalizes INR <10 minutes after administration. Intravenous vitamin K, which results in sustained warfarin reversal but takes 12-24 hours for full effect. Because of this delayed effect, vitamin K is always used with clotting factor replacement (Choice D). (Choice A) Fresh frozen plasma is considered the second-line therapy for replacing vitamin K-dependent clotting factors due to the large volume (often >2 L) required and the delay for blood compatibility tests. Fresh frozen plasma is typically used when prothrombin complex concentrate is unavailable. (Choice B) Intravenous desmopressin is a synthetic analog of antidiuretic hormone that increases circulating levels of factor VIII and von Willebrand factor. It is often used to treat minor bleeding episodes in patients with von Willebrand disease or uremic platelet dysfunction. This patient requires restoration of all vitamin K-dependent clotting factors, not just factor VIII. (Choice C) Intravenous idarucizumab is a monoclonal antibody used to reverse the anticoagulant dabigatran, a direct thrombin inhibitor. This patient was on warfarin, not dabigatran; idarucizumab would be ineffective. Educational objective: Life-threatening hemorrhage in patients on warfarin therapy should be treated with prothrombin complex concentrate and intravenous vitamin K.

A 73-Year-Old Woman Is Brought to the Emergency Department Due