# A client on apixaban for atrial fibrillation presents with intracerebral hemorrhage 90 minutes after the last dose. Which interventions are appropriate? Select all that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374979&lang=en  
> language: en  
> subject: Psychosocial Integrity  
> category: PSI

## Question

A client on apixaban for atrial fibrillation presents with intracerebral hemorrhage 90 minutes after the last dose. Which interventions are appropriate? Select all that apply.

1

Administer protamine sulfate to neutralize the apixaban

2

Administer andexanet alfa as the targeted reversal agent for apixaban

3

Administer 4-factor prothrombin complex concentrate if andexanet is unavailable

4

Lower systolic blood pressure to a target around 140 mm Hg

5

Administer fresh frozen plasma 4 units as first-line reversal

## Explanation

Apixaban is a direct factor Xa inhibitor. Targeted reversal is andexanet alfa; if unavailable, 4F-PCC (50 units/kg) is the recommended alternative. FFP does NOT reliably reverse direct oral anticoagulants and is no longer recommended. Protamine reverses HEPARIN, not apixaban. Aggressive BP control to a systolic around 140 mm Hg reduces hematoma expansion in spontaneous ICH. Idarucizumab reverses dabigatran (NOT apixaban).

## In-depth explanation

Reversal cheat sheet: warfarin→4F-PCC + vitamin K; dabigatran→idarucizumab; apixaban/rivaroxaban→andexanet alfa; heparin→protamine; LMWH→partial protamine.

## Clinical scenario

GCS 12, BP 196/108, last apixaban dose at 0700, weight 78 kg, no recent prothrombin complex.

## Key concepts

- **andexanet alfa** — Recombinant factor Xa decoy that binds and reverses apixaban/rivaroxaban.
- **4F-PCC** — 4-factor prothrombin complex concentrate; reverses warfarin and DOACs when targeted agent unavailable.
- **idarucizumab** — Monoclonal antibody fragment reversing dabigatran.

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