AEM Early Access 10: Air Ambulance Delivery and Administration of 4-Factor PCC

Welcome to the tenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM


Air Ambulance Delivery and Administration of Four-Factor Prothrombin Complex Concentrate is Feasible and Decreases Time to Anticoagulation Reversal. Claire Vines, PharmD, Stephanie J. Tesseneer, PharmD, Robert D. Cox, MD, PhD,
Damon A. Darsey, MD, Kristin Carbrey, PharmD, BCPS and Michael A. Puskarich, MD

(click on title for full text; open access through February 1, 2018)     

LISTEN NOW: INTERVIEW WITH corresponding AUTHOR DR.michael puskarich

Dr. Michael Puskarich

Michael Puskarich, MD

Associate Professor and Research Director

Department of Emergency Medicine

University of Mississippi Medical Center


Objectives: The objective was to evaluate the feasibility, safety, and preliminary efficacy of four-factor prothrombin complex concentrate (4-factor PCC) administration by an air ambulance service prior to or during transfer of patients with warfarin-associated major hemorrhage to a tertiary care center for definitive management (interventional arm) compared to patients receiving 4-factor PCC following transfer by air ambulance or ground without 4-factor PCC treatment (conventional arm).

Methods: This was a retrospective chart review of patients presenting to a large academic medical center. All patients presenting to the emergency department (ED) treated with 4-factor PCC from April 1, 2014, through June 30, 2016, were identified. For this study, only transfer patients with an International Normalized Ratio (INR) > 1.5 actively treated with warfarin were included. The primary outcome was the proportion of patients with an INR ≤ 1.5 upon tertiary care hospital arrival, and the secondary efficacy outcome was difference in time to achievement of INR ≤ 1.5. Additional safety and efficacy objectives included difference in thromboembolic complications, length of stay, intensive care unit length of stay, and inpatient mortality between groups.

Results: Of the 72 included patients, a higher proportion of patients in the interventional group had an INR ≤ 1.5 on ED arrival (proportion difference = 0.82, 95% confidence interval = 0.64–0.92, p < 0.0001) and significantly reduced time to observed INR ≤ 1.5 (181 minutes vs. 541 minutes, p = 0.001). No differences were observed in thromboembolic complications or patient-centered outcomes with the exception of mortality, which was significantly higher in patients in the interventional group. This group was also observed to have lower Glasgow Coma Scale score and higher intubation rates prior to transfer and treatment.

Conclusions: Dispatch of an air ambulance carrying 4-factor PCC with administration prior to transfer is feasible and leads to more rapid improvement in INR among patients with warfarin-associated major hemorrhage.


Race against the clock: overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhageJ Neurosurg. 2014 Aug;121 Suppl:1-20. doi: 10.3171/2014.