Show Notes

Toxicology & Pathophysiology

Often delayed + insidious
Severe coagulopathy may precede obvious bleeding
Early: epistaxis, gingival bleeding, bruising/ecchymoses, hematuria
Classic clue: well-appearing pt + extraordinarily abnormal coagulation studies
Severe bleeding: RP hemorrhage, ICH, spinal hemorrhage, tamponade, major GI/GU bleeding
RP bleed → flank/back pain ± CVA tenderness

PT/INR: profoundly elevated, sometimes beyond assay range
aPTT: may also be markedly prolonged with severe factor depletion
CBC/plts: often initially preserved unless major blood loss/other process
LFTs: often relatively normal
Profound INR + no warfarin + preserved liver function → think superwarfarin
CT based on bleeding site; CT A/P for suspected RP hemorrhage
Confirm: specialized serum/blood testing for long-acting anticoagulants, typically chromatography/mass spec
Do NOT delay resuscitation/treatment for confirmatory testing

Liver dz → abnormal hepatic profile/clinical context
DIC → ↓ plts, ↓ fibrinogen, ↑ D-dimer
No warfarin + massive INR + relatively normal LFTs/plts → superwarfarin rises on the differential

Goal: replace factors NOW + restore endogenous synthesis
4F-PCC = preferred factor replacement
- Fast, predictable correction
- Small volume
- No thawing/type matching
FFP if PCC unavailable
- Slower + large volume/TACO risk
Give IV vitamin K concurrently
PCC = immediate bridge; vitamin K = sustained factor synthesis
Recheck INR + clinical bleeding response
Repeat PCC generally not routine; reassess before redosing

Massive unexplained INR + relatively normal liver function → think superwarfarin
Major bleeding → 4F-PCC + IV vitamin K
Expect prolonged vitamin K therapy + meticulous INR follow-up