Management of major bleeding for anticoagulated patients in the Emergency Department: an European experts consensus statement

Authors: Backus, Ba; Beyer-Westendorf, J; Body, R; Lindner, T; Möckel, M; Sehgal, V; Parry-Jones, A; Seiffge, D; Gibler, B

Affiliations: Emergency Department, Franciscus Gasthuis and Vlietland, Rotterdam. Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands. Division of Thrombosis and Hemostasis, University of Dresden, Dresden, Germany. Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK. Emergency and Acute Medicine, Campus Virchow, Charité – Universitätsmedizin, Berlin, Germany. Department of Gastroenterology, University College London Hospital, London. Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK. Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance NHS Foundation Trust & University of Manchester, Manchester. Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK. Department of Neurology, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland. University of Cincinnati College of Medicine President, Department of Emergency Medicine, Cincinnati, Ohio, USA.

Publication: European journal of emergency medicine. 2023. 30. 315–323

ABSTRACT: An increasing number of patients presenting to the emergency department (ED) with life-threatening bleeding are using oral anticoagulants, such as warfarin, Factor IIa and Factor Xa inhibitors. Achieving rapid and controlled haemostasis is critically important to save the patient’s life. This multidisciplinary consensus paper provides a systematic and pragmatic approach to the management of anticoagulated patients with severe bleeding at the ED. Repletion and reversal management of the specific anticoagulants is described in detail. For patients on vitamin K antagonists, the administration of vitamin K and repletion of clotting factors with four-factor prothrombin complex concentrate provides real-time ability to stop the bleeding. For patients using a direct oral anticoagulant, specific antidotes are necessary to reverse the anticoagulative effect. For patients receiving the thrombin inhibitor dabigatran, treatment with idarucizamab has been demonstrated to reverse the hypocoagulable state. For patients receiving a factor Xa inhibitor (apixaban or rivaroxaban), andexanet alfa is the indicated antidote in patients with major bleeding. Lastly, specific treatment strategies are discussed in patients using anticoagulants with major traumatic bleeding, intracranial haemorrhage or gastrointestinal bleeding.