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visit JEMS.com/rs and enter 8.
(DDAVP) at 0.3–0.4 mg/kg to increase platelet adhesiveness and improve outcomes in this
patient population, though more research is
needed before definitive recommendations
can be made. 15, 16
The use of blood thinners has become more
common in the general population and the
number of anticoagulant and antiplatelet
medications available on the market have
also grown. Although these drugs can prevent patients from forming clots and stave
off medical maladies such as strokes, deep
venous thromboses and pulmonary emboli,
their complications will continue to be an
issue in the setting of hemorrhage. Even an
uncontrolled nosebleed can be lethal with the
wrong mix of these medications.
Becoming familiar with anticoagulants and
their respective reversal strategies will enable
providers to quickly and accurately adminis-
ter the proper reversal agents. Therefore, it’s
imperative that providers obtain a good med-
ication history to drive treatment in the right
direction. Skipping this vital step could lead to
delaying definitive care, which might be fatal.
Whenever we find ourselves with a bleeding
patient—no matter trauma or medical, young
or old—we should always be asking, “Is my
patient on any anticoagulation therapy?”
Patients may not understand the connec-
tion between their blood thinners and the
present trauma or illness, but as care provid-
ers we absolutely must. And if improving our
expediency to identify and treat these patients
requires us to revise our trauma alert practices
or criteria, then let us do so. As in this patient’s
case, identification of bleeding in the setting
of coagulopathy can expedite definitive treat-
ment and help to save a life. JEMS
1. Miller CS, Grandi SM, Shimony A, et al. Meta-analysis of efficacy
and safety of ne w oral anticoagulants (dabigatran, rivaroxaban,
apixaban) versus warfarin in patients with atrial fibrillation.
Am J Cardiol. 2012;110( 3):453–460.
2. Kamal AH, Tefferi A, Pruthi RK. How to interpret and pursue
an abnormal prothrombin time, activated partial thromboplastin time, and bleeding time in adults. Mayo Clin Proc.
3. Dager WE, Gosselin RC, Kitchen S, et al. Dabigatran effects on
the international normalized ratio, activated partial thromboplastin time, thrombin time, and fibrinogen: A multicenter, in
vitro study. Ann Pharmacother. 2012; 46( 12):1627–1636.
4. Sambu N, Curzen N. Monitoring the effectiveness of antiplatelet
therapy: Opportunities and limitations. Br J Clin Pharmacol.
5. Costa-Lima C, Fiusa MM, Annichino-Bizzacchi JM, et al. Prothrombin complex concentrates in warfarin anticoagulation
reversal. Rev Bras Hematol Hemoter. 2012; 34( 4):302–304.
6. Franchini M, Lippi G. Prothrombin complex concentrates: An
update. Blood Transfus. 2010; 8( 3):149–154.
7. Leissinger CA, Blatt PM, Hoots WK, et al. Role of prothrombin
complex concentrates in reversing warfarin anticoagulation: A
review of the literature. Am J Hematol. 2008;83( 2):137–143.
8. Johansen M, Wikkelsø A, Lunde J, et al. Prothrombin complex
concentrate for reversal of vitamin K antagonist treatment in
bleeding and non-bleeding patients. Cochrane Database Syst
Rev. 2015;( 7):CD010555.
9. Radaelli F, Dentali F, Repici A, et al. Management of anticoagulation in patients with acute gastrointestinal bleeding. Dig
Liver Dis. 2015; 47( 8):621–627.
10. Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for
dabigatran reversal. N Engl J Med. 2015;373( 6):511–520.
11. Eerenberg ES, Kamphuisen PW, Sijpkens MK, et al. Reversal
of rivaroxaban and dabigatran by prothrombin complex con-
centrate: A randomized, placebo-controlled, crossover study
in healthy subjects. Circulation. 2011;124( 14):1573–1579.
12. Connors JM. Antidote for Xa anticoagulants. N Engl J Med.
13. Alquwaizani M, Buckley L, Adams C, et al. Anticoagulants: A
review of the pharmacology, dosing, and complications. Curr
Emerg Hosp Med Rep. 2013; 1( 2):83–97.
14. Powner DJ, Hart well EA, Hoots WK. Counteracting the effects
of anticoagulants and antiplatelet agents during neurosurgical
emergencies. Neurosurgery. 2005; 57( 5):823–831.
15. Naidech AM, Maas MB, Levasseur-Franklin KE, et al. Desmopressin improves platelet activity in acute intracerebral hemorrhage. Stroke. 2014; 45( 8):2451–2453.
16. Kapapa T, Röhrer S, Struve S, et al. Desmopressin acetate in
intracranial haemorrhage. Neurol Res Int. 2014;2014:298767.
Brant Jaouen, MD, is an Emergency Medicine resident at
Maricopa Integrated Health System in Phoenix. He can be
reached at email@example.com.
Ben Stone, FP-C, is a flight medic working for Montrose
CareFlight on the western slopes of Colorado. He can be
reached at firstname.lastname@example.org.
Jennifer Belcher Jones, RN, CCRN, CFRN, is a flight nurse
and critical care nurse in the Southwest U.S. She can be
reached at email@example.com.
Jordan Kohler, NRP, is a paramedic with Incline Village
Nevada Fire, and a part-time paramedic with Humboldt Gen-
eral Hospital in Winnemucca, Nev., and a former Humboldt
General Hospital Air One Flight paramedic.
Ryan Hodnick, DO, NREMT-P, FAWM, is an EMS physician and critical care paramedic for multiple EMS agencies both ground and air throughout the Southwest U.S.
He is also an active flight crew member. He can be reached