1. Warfarin Toxicity Treatment & Management
BY FATEME YAGHOUBINEZHAD

2. 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

3. 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, mg daily is recommended many weeks.

4. 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).

5. 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, mg, orally

6. 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, mg

7. 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

8. 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

9. TANKS FOR ATTENTION