Anticoagulation management and reversal
This section summarises practical emergency department (ED) management of anticoagulant‑associated bleeding and excess anticoagulant effect, with emphasis on UK guidance (NICE, MHRA, RCEM).
It covers immediate actions for life‑threatening haemorrhage, agent‑specific reversal, laboratory interpretation, practical ED implementation and key decision points. Seek haematology and transfusion advice early for major bleeding or complex cases.
Principles
- Manage airway, breathing and circulation (ABCs) and local haemorrhage control first.
- Identify the anticoagulant, time and dose of the last administration, the indication for therapy (for example mechanical valve, recent VTE, high‑risk atrial fibrillation), and assess renal function because it affects DOAC clearance.
- For major or life‑threatening bleeding (including suspected intracranial haemorrhage) act promptly to reverse anticoagulation where indicated; activate the major haemorrhage protocol and contact transfusion and haematology teams (NICE NG24/CG141).
- Reversal agents are prothrombotic and should be used only when the expected benefit outweighs the thrombosis risk; consult specialists when possible.
- If a specific antidote is not available or not indicated, use non‑specific haemostatic measures (for example 4‑factor prothrombin complex concentrate or fresh frozen plasma) guided by local protocols.
- Document the indication for reversal, the rationale and the plan for restarting anticoagulation.