Synopsis
Assess bleeding severity and residual anticoagulant effect, restore physiology and source control, choose proportionate reversal and make a deliberate thrombosis-safe restart plan.
- Classify the clinical bleed first: critical site, haemodynamic compromise, uncontrolled loss or substantial transfusion need makes it major regardless of the laboratory result.
- Stop anticoagulant and unnecessary antiplatelets, resuscitate, correct temperature and calcium, and obtain source control; reversal alone cannot close a vessel or treat a lesion.
- Record exact drug, indication, dose, last dose time, renal trajectory, weight and interacting medicines before exposure information is lost during transfer.
Key red flags
New focal neurology, severe headache, reduced consciousness or significant head trauma demands immediate CT and anticoagulant reversal assessment even without shock.
Neurology, airway compromise, cord symptoms, tamponade, retroperitoneal pain or a tense compartment requires emergency action before large-volume loss is visible.
Investigation priorities
Assess loss, reserve, clearance and transfusion readiness.
Management branches
Bleeding is critical-site, haemodynamic, uncontrolled or requires major transfusion.
- Stop antithrombotics, activate ABCDE and major-haemorrhage care, obtain exposure and laboratory data and call the anatomical source-control team.
- Give drug-specific reversal or factor replacement using the warfarin, dabigatran, factor-Xa or heparin branch while correcting temperature, calcium and component deficits.
Key medicines
Warfarin reversalFor major bleeding give four-factor PCC using the stocked product's INR and weight table plus phytomenadione 5–10 mg by slow IV injection; for INR above 8 without bleeding use 1–5 mg oral phytomenadione and prompt recheck.
IdarucizumabGive 5 g intravenously as two consecutive 2.5 g/50 mL doses for dabigatran-associated life-threatening or uncontrolled bleeding or urgent surgery that cannot wait.