1. A 65-year-old man who is taking warfarin attends the emergency department with a headache and is found to have a subdural haemorrhage. His INR is 2.5 and GCS is 11. The neurosurgeons are going to take him to theatre for an emergency decompressive craniotomy. What is the most appropriate treatment?
A. Vitamin K alone
B. Vitamin K and four factor prothrombin complex concentrate
C. Vitamin K and fresh frozen plasma
D. Vitamin K and three factor prothrombin complex concentrate
E. Vitamin K and activated charcoal
2. A 74-year-old woman who is taking apixaban for a previous deep vein thrombosis attends the emergency department with abdominal pain and guarding. CT scan of the abdomen shows a large bowel perforation due to a ruptured diverticulum. She requires an urgent laparotomy and the surgeons contact haematology for advice. She last took apixaban 6 hours ago. What is the most appropriate management of her anticoagulation?
A. Administer andexanet alfa
B. Administer four-factor prothrombin complex concentrate
C. Administer idarucizumab
D. Administer two units of platelets
E. Proceed with surgery and monitor for bleeding
3. A 67-year-old man with atrial fibrillation who recently had primary percutaneous coronary intervention for a STEMI is taking aspirin, clopidogrel and rivaroxaban is admitted to a hospital in London with a decreased consciousness and secondary to a spontaneous intracerebral haemorrhage. He last took all three medications 10 hours ago. His INR is 1.5. What is the most appropriate management?
A. Administer andexanet alfa
B. Administer andexanet alfa and two units of platelets
C. Administer four-factor prothrombin complex concentrate
D. Administer two units of platelets and four-factor prothrombin complex concentrate
E. Observe only
4. A 73-year-old woman is taking edoxaban for secondary prevention after a DVT five years ago. She is admitted to the emergency department with haematemesis and melaena. Her blood pressure is 105/70, heart rate 95 beats per minute, and her haemoglobin is 115 g/l. She last took 60 mg edoxaban 20 hours ago. What is the most appropriate management?
A. Administer andexanet alfa
B. Administer prothrombin complex concentrate
C. Check INR and if elevated, administer andexanet alfa
D. Check INR and if elevated, administer four-factor prothrombin complex concentrate
5. A 33-year-old woman taking therapeutic low molecular weight heparin for DVT is 36 weeks pregnant and arrives at the emergency department following a road traffic collision. She has a splenic laceration and is haemodynamically unstable. She last took her 15,000 units of dalteparin 6 hours ago. The team decide that reversal is required. What is the most appropriate dose of protamine sulfate?
A. Protamine sulfate 25 mg
B. Protamine sulfate 50 mg
C. Protamine sulfate 75 mg
D. Protamine sulfate 100 mg
E. Protamine sulfate 150 mg
6.Normal standard tests of coagulation do not rule out therapeutic drug levels of DOACs except:
A. Apixaban, activated partial thromboplastin time (aPTT)
B. Dabigatran, thrombin time (TT)
C. Edoxaban, prothrombin time (PT/INR)
D. Rivaroxaban, prothrombin time (PT/INR)
7. An 83-year old woman on apixaban 5 mg BD for atrial fibrillation is admitted with haematemesis and malaena requiring resuscitation with 2 units of packed red cells and 3,000 IU of prothrombin complex concentrate. Gastroscopy revealed severe erosive oesophagitis and gastritis. She was started on high dose proton-pump inhibitor and made a good recovery. The ward doctor calls you 2 weeks later as they are thinking of discharging her and ask for advice regarding her anticoagulation. She weighs 65 kg and her creatinine is 76 μmol/l.
What would you advise for her anticoagulation from today going forwards?
A. Do not restart anticoagulation
B. Restart apixaban at a lower dose of 2.5 mg twice daily
C. Restart apixaban 5 mg twice daily
D. Switch to edoxaban 60 mg once daily
E. Switch to therapeutic dose low molecular weight heparin
8. A 73-year-old man who is taking apixaban 5 mg BD for treatment of a DVT is admitted to hospital in Glasgow with right=sided weakness and a decreased level of consciousness (GCS 10). A CT scan shows an acute left frontal intracerebral haemorrhage. He last took apixaban 6 hours ago and his INR is 1.1.
What is the most appropriate management?
A. Andexanet alfa 400 mg bolus then 480 mg infusion over 120 minutes
B. Andexanet alfa 800 mg bolus then 960 mg infusion over 120 minutes
C. Four factor prothrombin complex concentrate 25 units/kg
D. Four factor prothrombin complex concentrate 50 units/kg
9. A 69-year-old woman is taking rivaroxaban 20 mg daily for atrial fibrillation and she last took a dose 7 hours ago. She is admitted to hospital in Leeds after having two episodes of malaena. On admission she is tachycardic and hypotensive and a point of care haemoglobin is 63 g/l. She is transfused two units of red cells but has a further three episodes of malaena. What is the most appropriate treatment?
A. Andexanet alfa 400 mg bolus then 480 mg infusion over 120 minutes
B. Andexanet alfa 400 mg bolus then 960 mg infusion over 120 minutes
C. Andexanet alfa 800 mg bolus then 960 mg infusion over 120 minutes
D. Four factor prothrombin complex concentrate 25 units/kg
E. Four factor prothrombin complex concentrate 50 units/kg
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