Warfarin Toxicity Treatment & Management BY FATEME YAGHOUBINEZHAD

Emergency Department Care Evaluate for current or remote bleeding , significant bleeding : transfusions of packed red blood cells (RBCs), fresh frozen plasma (FFP), IV/oral vitamin K1

Acute ingestion For acute ingestions, no evidence of bleeding on the initial clinical Examination. Obtain a baseline PT/INR (repeat measurement in 24-48Hours) activated charcoal (Gastric lavage is unnecessary if rapid administration of activated charcoal is feasible. Do not induce emesis.) Do not administer vitamin K1 prophylactically. Elevated PT : vitamin K1(Ten milligrams orally daily) for more than several days. Superwarfarin induced coagulopathies, 50-200 mg daily is recommended many weeks.

Chronic intoxication the INR is higher than therapeutic levels but less than 5 and the patient is not bleeding: withhold warfarin for 2-3days (restart when the INR approaches the therapeutic range) If the patient requires more rapid reversal (elective surgery) : 12.5mg of vitamin K1 orally ( the INR will begin to fall within 8 hours, with a maximal effect in about 24hours).

Chronic intoxication If the INR is higher than 5 but less than 9 and the patient is not actively bleeding: withhold warfarin for the next 1 or 2 doses, monitor the INR more frequently (resume therapy at a lower dose when the INR is at the therapeutic level) Another therapeutic approach would be withhold 1 dose of warfarin orally administer vitamin K1, 1-2.5mg, if the patient is at increased risk of bleeding. For more rapid reversal (urgent surgery) : vitamin K1, 2.5-5 mg, orally

Chronic intoxication If the INR is higher than 9 and the patient is not bleeding, a higher daily dose of oral vitamin K1 (5-10mg) may be administered. In the setting of superwarfarin induced coagulopathies, 50-200mg

Treatment of serious hemorrhage Active, serious hemorrhage should be treated with FFP( 15 mL/kg ) Alternatively, recombinant factor VIIa (rFVIIa) or prothrombin complex concentrate, human(Kcentra) vitamin K1, 10 mg, by slow IV infusion

Follow-Up Patients who are already on warfarin, an unintentional overdose, and hemodynamically stable with no evidence of active bleeding: follow up with their regular source of anticoagulation care routine INR monitoring for patients on stable warfarin dosing : further than every 4 weeks

TANKS FOR ATTENTION