Emergency medicine · core
Warfarin reversal
In warfarin-associated intracerebral haemorrhage, NICE NG128 recommends four-factor prothrombin complex concentrate plus intravenous vitamin K. Vitamin K alone is too slow; fresh frozen plasma is not first-line when PCC is available.
Why this is high-yield for the UKMLA AKT
UKMLA AKT stems often pair a life-threatening bleed with an anticoagulant the candidate already “knows”. The trap is treating the bleed as a general GI-bleed reversal (FFP, “just give vitamin K”) instead of the ICH-specific sequence. This presentation sits on the MLA emergency and stroke areas and is tested because the wrong first drug costs brain.
The question
A 74-year-old man is brought to the emergency department after collapsing at home. He has atrial fibrillation and takes warfarin. His Glasgow Coma Scale score has fallen from 14 to 10 in the ambulance. Non-contrast CT of the head shows a large left intracerebral haemorrhage. His INR is 3.4. He is not taking antiplatelets. Blood pressure is 168/94 mmHg. There is no history of head trauma.
What is the most appropriate immediate pharmacological management of his coagulopathy?
- A. Fresh frozen plasma only
- B. Intravenous vitamin K only
- C. Four-factor prothrombin complex concentrate plus intravenous vitamin K
- D. Tranexamic acid only
- E. Platelet transfusion
Reveal the worked answer
Correct answer: C. Four-factor prothrombin complex concentrate plus intravenous vitamin K
A — FFP can replace clotting factors but requires a large volume, takes longer to infuse, and corrects the INR less predictably than four-factor PCC. NICE prefers PCC for vitamin K antagonist–associated ICH when it is available.
B — Intravenous vitamin K is required, but it is not sufficient on its own. Hepatic synthesis of vitamin K–dependent factors takes hours. An expanding ICH needs immediate factor replacement, not a delayed INR drift.
C (correct) — This is the NICE NG128 sequence for intracerebral haemorrhage in a patient taking a vitamin K antagonist with a raised INR: reverse promptly with four-factor PCC and give intravenous vitamin K so the INR does not rebound when the PCC wears off.
D — Tranexamic acid is used in some traumatic and postpartum bleeds. It does not reverse warfarin. The coagulopathy here is a vitamin K antagonist effect, not fibrinolysis as the primary problem.
E — He is not on an antiplatelet and there is no stated thrombocytopenia. Platelets do not reverse warfarin. Transfusing them here delays the treatment that actually lowers the INR.
Clinical pearl. PCC replaces the factors now; intravenous vitamin K keeps them coming. Order both. Do not wait for a “safer” INR before arranging imaging review and blood-pressure control.
MLA Content Map. Acute and emergency care · Stroke and intracranial haemorrhage
Guideline. NICE guideline NG128 — Stroke and transient ischaemic attack in over 16s (NG128)
Key facts to remember
- First-line reversal of warfarin-associated intracerebral haemorrhage (NICE NG128)?
- Four-factor prothrombin complex concentrate plus intravenous vitamin K.
- Why is intravenous vitamin K alone too slow in ICH?
- Vitamin K restarts hepatic synthesis of factors II, VII, IX and X over hours. An expanding haematoma needs immediate factor replacement.
- Why is fresh frozen plasma not first-line when PCC is available?
- FFP needs a larger volume, infuses more slowly, and corrects the INR less reliably than four-factor PCC.
- Why give vitamin K as well as PCC?
- PCC is temporary. Intravenous vitamin K prevents the INR from climbing again as the concentrate is cleared.
Frequently asked questions
What reverses warfarin in intracranial haemorrhage?
NICE NG128 recommends four-factor prothrombin complex concentrate plus intravenous vitamin K for intracerebral haemorrhage in a patient taking a vitamin K antagonist with a raised INR.
Is fresh frozen plasma acceptable first-line treatment for warfarin ICH?
Not when four-factor PCC is available. FFP is a slower, higher-volume alternative and is not the NICE first-line choice for this presentation.
Should you delay reversal until after neurosurgical review?
No. Reverse the coagulopathy as soon as ICH is confirmed and the INR is raised. Imaging review and blood-pressure control run in parallel — they do not replace reversal.
Related learning paths
Educational content for exam preparation — always follow your local guidelines in practice. See our editorial standards.