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

Barbra Backus, Jan Beyer-Westendorf, Rick Body, Tobias Lindner, Martin Möckel, Vinay Sehgal, Adrian Parry-Jones, David Seiffge, Brian Gibler

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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.

Original languageEnglish
Pages (from-to)315-323
Number of pages9
JournalEuropean Journal of Emergency Medicine
Issue number5
Early online date7 Jul 2023
Publication statusPublished - 1 Oct 2023


  • algorithm
  • anticoagulants
  • direct oral anticoagulants
  • emergency department
  • gastrointestinal bleeding
  • intracranial haemorrhage
  • major bleeding
  • trauma
  • treatment
  • vitamin K antagonists


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