Anticoagulation Reversal in Trauma
Rapid identification and reversal of pre-injury anticoagulants — critical in TBI and hemorrhagic trauma.
Updated: 2024–2025
AnticoagulationWarfarinDOACPCCIdarucizumabAndexanetReversalOn this page3 sectionsHide sections
No local AHS protocol — general educational reference only. Use with attending guidance and institutional policy.
⚠️ General educational reference — no confirmed AHS local reversal protocol. STAT pharmacy/hematology consult required.
⚠️ Always identify the specific anticoagulant before selecting reversal agent.
⚠️
No local AHS anticoagulation reversal protocol has been uploaded. Use as general educational reference. STAT pharmacy/hematology consult required in all cases.
💊Reversal by Agent
▼| Anticoagulant | Reversal Agent | Notes |
|---|---|---|
| Warfarin (Coumadin) | 4-factor PCC (Kcentra) + IV Vitamin K | PCC for rapid reversal (minutes); Vit K for sustained effect (hours). INR goal <1.5 for procedures. |
| Rivaroxaban (Xarelto) Apixaban (Eliquis) Direct Xa inhibitors | Andexanet alfa (Andexxa) OR 4-factor PCC | Andexanet alfa is the specific reversal agent. 4-factor PCC is a reasonable alternative if andexanet not available. |
| Dabigatran (Pradaxa) Direct thrombin inhibitor | Idarucizumab (Praxbind) 5g IV | Specific monoclonal antibody — highly effective reversal. |
| Heparin (UFH) | Protamine sulfate | 1mg protamine per 100 units heparin given in last ~2–3h. Give slowly IV. |
| Enoxaparin (LMWH) | Protamine sulfate (partial reversal) | 1mg protamine per 1mg enoxaparin given in last 8h. ~60% effective. |
| Antiplatelets (ASA, clopidogrel, ticagrelor) | Clinical judgment; platelet transfusion if actively bleeding | Routine platelet transfusion not recommended solely to reverse antiplatelets. Discuss with neurosurgery if TBI. |
🔍Identifying the Agent
▼- Ask family, EMS, pharmacy — wallet cards, medication bottles
- Review Epic medication reconciliation if prior AHS/UCSF encounter
- INR elevated → warfarin likely; INR normal + active bleeding → DOAC likely
- Anti-Xa level confirms heparin, LMWH, or direct Xa inhibitors
- Prolonged thrombin time (TT) → dabigatran
- In TBI emergency: Do not delay reversal waiting to confirm agent — assume anticoagulation and treat
🧠TBI + Anticoagulation
▼- Time-critical — intracranial bleeding can expand rapidly on anticoagulation
- Warfarin ICH: 4-factor PCC reverses INR in minutes vs hours for vitamin K alone — use PCC first
- Serial CT scanning required to assess progression
- Platelet transfusion for antiplatelet + TBI: discuss with neurosurgery — evidence mixed for clopidogrel
- Geriatric patients: most common anticoagulation scenario in trauma — prioritize agent identification
- Status
- General Educational Reference
- Source
- Popma E et al. JTACS 2025 · ACS TBI Best Practices 2024 · ACS Geriatric Trauma Guidelines 2023
- Last reviewed / updated
- 2024–2025