title: Managing bleeding in anticoagulated patients in the emergency care setting.
abstract: BACKGROUND
  Orally administered anticoagulants that offer alternatives to warfarin have been developed in recent years and are currently available for reduction of stroke risk in patients with non-valvular atrial fibrillation, the prophylaxis of venous thromboembolism after hip or knee replacement surgery, and the treatment and secondary risk reduction of deep vein thrombosis and pulmonary embolism.
  
  
  OBJECTIVE
  This article will provide a brief introduction to these new oral anticoagulants and then review the approaches that can be taken for the emergency management of hemostasis in patients bleeding or at risk for bleeding while receiving warfarin or one of two newer agents, the direct thrombin inhibitor dabigatran or the factor Xa inhibitor rivaroxaban.
  
  
  CONCLUSIONS
  Oral anticoagulant use is widespread and likely to continue to increase. Warfarin has been the standard of care in oral anticoagulation for many years; its bleeding risks are well known and associated emergency protocols are well established. As newer oral anticoagulants become more widely used, similar procedures will need to be developed. Although there are as yet no specific reversal agents for these newer drugs, recommendations for overdose, emergency hemostasis, and preoperative management are available. Further, while the newer agents do not require routine coagulation monitoring, assays for use in non-routine situations are being explored.
  
  
  CONCLUSIONS
  The introduction of alternative oral anticoagulants will require emergency procedures that differ in some respects from those currently in place for warfarin and it will be necessary for Emergency Medicine professionals to become familiar with these procedures. Clinical stabilization of the bleeding or at-risk patient remains the emergency physician's priority.
authors.affiliation: Department of Emergency Medicine, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania 19107, USA.
authors.forename: Charles V
authors.initials: CV
authors.lastname: Pollack
mesh_terms: D000925:Anticoagulants / Q000009:adverse effects*; D000931:Antidotes / Q000627:therapeutic use; D001562:Benzimidazoles / Q000009:adverse effects*; D000069604:Dabigatran; D004636:Emergency Service, Hospital; D006470:Hemorrhage / Q000628:therapy*; D006487:Hemostasis / Q000187:drug effects; D006801:Humans; D009025:Morpholines / Q000009:adverse effects*; D000069552:Rivaroxaban; D013876:Thiophenes / Q000009:adverse effects*; D014859:Warfarin / Q000009:adverse effects*; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000925:Anticoagulants; D000931:Antidotes; D001562:Benzimidazoles; D009025:Morpholines; D013876:Thiophenes; D015091:beta-Alanine; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran
keywords: anticoagulant; antidote; bleeding; dabigatran; rivaroxaban