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How to Stop Bleeding in the ER Caused by Warfarin

Prothrombin complex concentrates (PCCs) are faster and more effective than fresh frozen plasma at reversing hemorrhage caused by the anti-coagulant warfarin, despite plasma being the most commonly used therapy.

A literature review published last month in Annals of Emergency Medicine suggests that physicians in the United States should join those around the world in following recommendations of multiple specialty organizations to use PCCs as the first line of defense in this common and life-threatening emergency (“Rapid Reversal of Warfarin-Associated Hemorrhage in the Emergency Department by Prothrombin Complex Concentrates”).

“The typical remedies for hemorrhage caused by warfarin are slow and unpredictable,” said author Kenneth Frumkin, PhD, MD of the Naval Medical Center in Portsmouth, Va. “By contrast, prothrombin complex concentrates reverse warfarin anticoagulation in minutes rather than hours. Its relative underuse in the U.S. compared to other countries seems to derive from lack of familiarity and infrequent availability.”

PCCs (products made from pooled human plasma) were initially developed to treat hemophilia. They can be infused rapidly and generally reverse anticoagulation three to five times faster than fresh frozen plasma, which must be thawed. Recombinant Activated Factor VII (Factor rVIIa), while approved in the United States only for surgery or bleeding in hemophiliacs, has been used to reverse warfarin-associated bleeding. Factor rVIIa works faster than fresh frozen plasma, but carries more risk and costs much more.

“The April 2013 approval by the Food and Drug Administration of a form of PCC specifically intended for warfarin reversal should expand the use of these life-saving products,” said Dr. Frumkin.

The views expressed by Dr. Frumkin are his own, and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information, visit

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