SAQ 218 – Haematology and Trauma – NOAC reversal and thromboelastography

Question 7. NOAC reversal and thromboelastography.

a. Indications for reversal

• Recent NOAC ingestion, generally within 12 hours.
• Clinically significant life-threatening bleeding.

b. Activated charcoal

• Consider for clinically significant bleeding after recent ingestion.
• It is most useful within two hours, with longer windows suggested for some agents.

c. Dialysis

• It is useful for dabigatran, but not highly protein-bound rivaroxaban or apixaban.
• Consider for life-threatening bleeding, renal impairment, markedly prolonged APTT, or very high dabigatran level.

d. Dabigatran reversal agents

• Tranexamic acid.
• Prothrombin complex concentrate.
• Idarucizumab.

e. Thromboelastography

• May detect and monitor NOAC activity, although this role is evolving.
• May predict the need for blood transfusion in trauma-induced coagulopathy.
• May guide use of FFP, cryoprecipitate, platelets, and tranexamic acid.