Anticoagulant related Intracranial Bleeds

All cases of ICH send stat labs : Platelets, PT, INR, PTT, Fibrinogen

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

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

(Apixaban/Eliquis, Rivaroxaban/Xarelto, Betrixaban/Bevyxxa, Endoxaban/Savaysa, Fondaparinux/Arixtra)

PCC 25 U/kg

Maintain diuresis

Activated charcoal if last dose within 2 hours

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.

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