The Royal London and Queen's Romford Neurosurgery Society

Correcting Coagulopathies

direct oral anticoagulants and anti-platelet agents in elderly patients with traumatic brain injury

Suthesh Sivapalaratnam – Haematology Registrar

As the population ages, neurosurgeons are confronted with a growing number of trauma patients receiving antithrombotic and antiplatelet medication prior to injury. In cases of traumatic brain injury, pre-injury treatment with anticoagulants has been associated with an increased risk of posttraumatic intracranial haemorrhage. Since high age itself is a well-recognised risk factor in traumatic brain injury, this population is at special risk for increased morbidity and mortality. The effects of antiplatelet medication on coagulation pathways in posttraumatic intracranial haemorrhage are not well understood, but available data suggest that the use of these agents increases the risk of an unfavourable outcome, especially in cases of severe traumatic brain injury (Benyon et al, 2012).

In this session, Dr Sivapalaratnam reviewed the mechanism of action of direct and indirect anticoagulants and potential reversal agents. He presented evidence and guidelines for reversal of anticoagulants and optimisation of platelet function in elderly patients with TBI taking antiplatelet agents. We agreed to audit our current practice and to consider revising our local protocols together.

How to REVERSE anticoagulation?

  • Protamine 1mg for every 100 units used in last 2-3 hours
  • Max. 50mg
  • Maximum speed 5mg/min
  • Vitamin K
  • PCC – 50 IU/kg (capped)
  • You can’t very effectively
  • Prophylaxis: Nothing
  • Therapeutic: Protamine?
  • <8 hours (above dosing)
  • >8 hours (less)
  • Novo7?
  • Idarucizumab (dabig)
  • Andexanet-alfa (rivarox)
  • Active Coal? , 2hrs
  • PCC
  • 50 IU/kg (capped)
  • Dialysis for dabigatran


Platelets – BSH – Guidelines – Dec 16

  • Keep platelets > 100×106/ml if neurosurgery
  • Keep platelets > 100×106/ml if traumatic brain injury


“Platelet transfusion seems inferior to standard care for people taking antiplatelet therapy before intracerebral hemorrhage. Platelet transfusion cannot be recommended for this indication in clinical practice.”

Clinical Take Home Point: To date this is the best evidence available, and based on this trial, platelet transfusion should be held in patients with acute non-traumatic intracerebral hemorrhage in patients taking antiplatelet therapy as patient outcomes seemed to be worsened.

PATCH-Trauma Study

The Pre-hospital Anti-fibrinolytics for Traumatic
Coagulopathy & Haemorrhage Study

The PATCH-Trauma Study is an international multi-centre, randomised, double-blind, placebo-controlled trial of pre-hospital treatment with tranexamic acid for severely injured patients at risk of acute traumatic coagulopathy. The study aims to determine the effects of early administration of tranexamic acid on survival and recovery of severely injured patients treated within advanced trauma systems.


Essential Reads
  • BSH guidelines (read recommendations)
    • Reversal of antithrombotic therapy
    • Platelet transfusion guidelines
  • ICH reversal antithrombotic therapy guideline
    • Frontera 2016
  • PATCH trial
    • Lancet 2016



Beynon C, Hertle DN, Unterberg AW, Sakowitz OW. Clinical review: Traumatic brain injury in patients receiving antiplatelet medication. Critical Care. 2012;16(4):228. doi:10.1186/cc11292.


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