A 93 yo female with a history of afib and rivaroxaban therapy presents after being found unresponsive.  She is intubated in the ED and a head CT is done?  What's the diagnosis?  Scroll down for answer.

Answer:  Non-traumatic intraparenchymal hemorrhage with midline shift

Despite her inevitably poor prognosis, her family insists that you do everything.  You call neurosurgery and set out to reverse the anticoagulation.

DOAC (Direct Oral Anticoagulation) Reversal

• Dabigatran is a direct thrombin inhibitor, while apixaban and rivaroxaban are factor Xa inhibitors
• Realtively short half lives.  Withholding dose usually sufficient in minor cases.  Major cases, such as the one above, require reversal.
• Dabigatran is dialyzable
• Recently FDA approved drugs for reversal: Idarucizumab to reverse dabigatran and Coagulation factor Xa (recombinant), inactivated-zho or the Xa inhibitors
• Fixed dose 4-factor prothrombin complex concentrate (4f-PCC)or activated prothrombin complex concentrate (aPCC) are recommended for reversal of these agents as well
• Consider tranexamic acid (TXA)
• Few in vitro studies suggest possible benefit with recominant factor VIIa, however data is limited and there are dosing impracticalities and possible pro-thrombotic effects - not currently recommended
• Could consider activated charcoal in intubated patient if last dose within 2 hours
• Consider fresh frozen plasma (FFP) if PCC not available

References:

Andexxa—An Antidote for Apixaban and Rivaroxaban. JAMA. 2018;320(4):399–400. doi:10.1001/jama.2018.9257

Christos S, Naples R.  Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016.  West J Emerg Med. 2016.  17(3): 264–270.

Frontera JA et al.  Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage.  Neurocritical Care.  2016. 24(1): 6-46