ICU Decoded › Library › Ward Pathways › Miscellaneous › Coagulopathy in the Bleeding PatientCoagulopathy in the Bleeding PatientICU / resuscitation
Miscellaneous · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 21 October 2026
Presentation Post-operative patient oozing from every puncture site; INR 2.1, platelets 68 × 10⁹/L, fibrinogen 1.1 g/L, temperature 34.8 °C
Red flags Oozing from every line site Fibrinogen below 1.5 g/L Falling platelets with a rising D-dimer Ionised calcium below 1.0 mmol/L Differential diagnosis DIC Dilutional coagulopathy Liver failure Uraemic platelet dysfunction Drug effect Heparin-induced thrombocytopenia Thrombotic microangiopathy When to admit, call ICU or discharge Admit: Any bleeding needing blood productsICU: Massive transfusion, DIC with organ failure, or bleeding that needs vasopressor supportKey points Source control first — products only buy time. Lethal triad: cold, acidotic, coagulopathic — add hypocalcaemia and it becomes a diamond. Reverse by drug: warfarin → 4F-PCC + vitamin K; dabigatran → idarucizumab; apixaban/rivaroxaban → 4F-PCC; heparin → protamine. Never Give FFP to correct an INR in a non-bleeding patient with liver disease Forget calcium and warming during massive transfusion Give platelets for antiplatelet-associated spontaneous intracerebral haemorrhage (PATCH) Give tranexamic acid for upper GI bleeding (HALT-IT) Treat DIC with products alone and not the trigger Common mistakes Chasing the INR with FFP in liver disease when the patient is not bleeding Forgetting calcium during massive transfusion Treating DIC with products instead of treating the trigger Transfusing platelets for antiplatelet-related intracerebral haemorrhage Leaving the patient cold Disposition and follow-up Correct while the source is being controlled; the coagulopathy is a symptom, and it recurs until the surgeon, endoscopist or radiologist has finished.
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