A 72-year-old male taking warfarin presents with an acute subdural hematoma and an INR of 4.8. What is the most rapid reversal therapy?

Answer and explanation

Correct answer: A. Four-factor prothrombin complex concentrate and vitamin K

  1. Step 1: Life-threatening intracranial bleeding on warfarin requires immediate restoration of vitamin K-dependent coagulation factors (II, VII, IX, X).
  2. Step 2: Four-factor prothrombin complex concentrate (4F-PCC) rapidly normalizes INR within minutes with minimal volume overload, co-administered with intravenous vitamin K to ensure sustained hepatic factor synthesis.
Answer
Four-factor prothrombin complex concentrate and vitamin K.
Why not the others: Oral vitamin K requires 12 to 24 hours to stimulate new hepatic clotting factor synthesis, which is far too slow for intracranial hemorrhage. Protamine sulfate specifically reverses unfractionated heparin, having zero efficacy against warfarin. Fresh frozen plasma requires large infusion volumes over hours and takes significantly longer to achieve complete INR normalization.

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