Bleeding patients present all sorts of dilemmas in emergency medicine, but perhaps the most gut wrenching is the patient bleeding on anticoagulant medication. Dabigatran is the latest anticoagulant on the market and is sure to give emergency doctors everywhere headaches.
Dabigatran (Pradaxa) is the most recently released oral anticoagulant. It has become popular as an alternative to Coumadin/Warfarin because there is no need for blood level monitoring. It is a direct thrombin inhibitor (though the suffix-an in other anticoagulants tends to imply Xa inhibition it has no Xa activity). It is approved for prevention of thromboembolism for non-valvular atrial fibrillation, and it is also being used widely for off label indications such as venous thromboembolism, pulmonary embolism, thrombophillias, and post operative prophylaxis. Dabigatran has a fairly short half life, 7-9 hours initially stretching to 12-17 hours with chronic use. It is therefore taken as a BID medication.
There is no antidote for dabigatran. It has a low volume of distribution and is dialyzable, though this is probably more important in overdose than in life threatening bleeding. Various sources recommend fresh frozen plasma, prothrombin complex concentrates (PCC/Octaplex) and recombinant factor use in the critically bleeding patient on dabigatran.
In general there is not yet a consensus of how to manage the patient taking dabigatran who presents with life threatening bleeding.
My own view is that these patients need prompt and aggressive management including the following steps: