How is serious hemorrhage due to warfarin and superwarfarin toxicity treated?

Updated: Jan 19, 2018
  • Author: Kent R Olson, MD, FACEP; Chief Editor: David Vearrier, MD, MPH  more...
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Active, serious hemorrhage should be treated with four-factor prothrombin complex concentrate (PCC), if available. [12] While costly, an essential advantage PCC confers to emergency care is that, in contrast to FFP, it results in a more rapid reversal of coagulopathy and does not require thawing or blood group typing. Additionally,it has a reduced risk of volume overload, transfusion-related acute lung injury, transfusion reactions, and infectious disease transmission. Despite these advantages, no mortality benefit has been proven for PCC compared with FFP.

Alternatively, recombinant factor VIIa (rFVIIa) has been reported to be effective in rapidly lowering INR due to warfarin toxicity and may be considered if PCC is not available. FFP is effective at lowering the INR and was historically first-line therapy for warfarin toxicity with serious or life-threatening bleeding, although it has now been superceded by PCC, which lowers the INR more rapidly. If PCC or rFVIIa are not available, 4 units of FFP may be administered instead. 

Administer vitamin K1, 10 mg, by slow IV infusion. Using IV vitamin K1 is rarely associated with an anaphylactoid reaction. If that occurs, the infusion should be stopped for 15 minutes, diphenhydramine administered, and vitamin K1 then restarted at a lower infusion rate. 

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