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Ann Emerg Med. 2019 Nov 13. pii: S0196-0644(19)31181-3. doi: 10.1016/j.annemergmed.2019.09.001. [Epub ahead of print]

Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel.

Author information

1
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Electronic address: cbaugh@bwh.harvard.edu.
2
Department of Emergency Medicine, Keck School of Medicine at the University of Southern California, Los Angeles, CA.
3
Department of Emergency Medicine, Regional West Health Systems, Scottsbluff, NE.
4
Department of Emergency Medicine, Tampa General Hospital, Tampa, FL.
5
Department of Emergency Medicine, Swedish/Mill Creek, Everett, WA.
6
Presbyterian Healthcare Services, University of New Mexico College of Pharmacy, Albuquerque, NM.
7
Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.
8
Department of Medicine, Section of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH.
9
Seton Dell Medical School Stroke Institute, Austin, TX.
10
Department of Emergency Medicine, Baylor College of Medicine, Houston, TX.
11
Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA.
12
Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA.
13
Department of Pathology and Internal Medicine (Hematology/Oncology), University of Texas Southwestern Medical Center, Dallas, TX.
14
Department of Medicine, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.
15
Department of Medicine, University of Virginia Health System, Charlottesville, VA.
16
Department of Surgery, Cox Medical Center, Springfield, MO.
17
Department of Emergency Medicine, Augusta University, Augusta, GA.
18
Department of Emergency Medicine, Covenant Medical Center, Lubbock, TX. Electronic address: williamsja@usacs.com.

Abstract

Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.

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