Managing the Clot and Bleed Challenge for VTE

Approximately one third of untreated DVT results in potentially fatal pulmonary embolism (PE), one third will suffer from post-thrombotic syndrome manifest with chronic lower leg edema, pain, pigment changes and skin breakdown, and one third will have a recurrent event within 10 years. PE has been cited as the most common preventable cause of death among hospitalized patients. Rapid diagnosis and treatment of DVT is essential to prevent these complications.

Testing should be undertaken as quickly as possible. However, if there will be a significant delay, patients with a moderate/high or likely pre-test probability of DVT/PE should receive a rapidly acting anticoagulant (e.g. low-molecular-weight heparin or a direct oral anticoagulant) until testing is performed, unless they are at high risk of bleeding or have another contraindication to anticoagulant therapy.

Oral anticoagulants (OACs) are used for the prevention and treatment of venous thromboembolism (VTE), however, bleeding is a major complication of OAC therapy. Clinicians have questions about optimal management of VTE, and the resulting clinically significant bleeding related to OAC use. This CAEP Note serves as a guide for clinicians to optimally manage VTE, bleeding events or urgent procedures in anticoagulated patients.

Authors

Indraneel Ghosh, MD CCFP (EM)
Eddy Lang, MDCM-CCFP(EM)-CSPQ
Mark Mensour, MD CCFP EM FPA FCFP
Anas Nseir, MD, CCFP, FCFP, B Pharm

Suspected Deep Vein Thrombosis

  • 35 y/o female presents to ED with lower leg pain for the previous 2 days and complains of left leg swelling after recent long flight
  • No cough, shortness of breath, chest or back pain
  • Past medical history:
    • Non-smoker
    • Meds- Birth control pills, acetaminophen, 650 mg TID for 2 days for leg pain
  • Examination
  • Actions
  • BP 128/76
  • Pulse 72/min regular
  • Respiratory rate 16/min
  • Cardiac and chest auscultation: normal
  • Left leg exam:
    • No skin redness
    • Normal distal pulses
    • Left leg swelling significant, left leg circumference more than 3.5 cm greater than right leg.
      • Two Level Wells Score For DVT Diagnosis10
        DVT Risk Factors:

        • Tenderness in calf
        • Swelling 3.5 cm greater than right side (10 cm below tibial tuberosity)
        • No pitting oedema
        • No varicose veins
        • No alternative diagnosis more likely
          Wells score = 2: DVT Likely
    • Use Algorithm for DVT diagnosis = When likely, order leg ultrasound.

Discussion:

  • Guidelines state: anticoagulation should be started immediately* in patients with a Likely Pretest Probability of DVT/PE5 *applies only in patients with a low risk of bleeding
    • 2.2.1. In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests (Grade 2C)
    • 2.2.2. In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Grade 2C)
    • 2.2.3. In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (Grade 2C)
    • 1 Grade 2C: Weak recommendations, low grade evidence
    • Remarks: Initial parenteral anticoagulation is given before dabigatran and edoxaban, is not given before rivaroxaban and apixaban…

Treament:

You ordered an ultrasound, but you will only get it tomorrow5.

  • Begin initial treatment for antithrombotic dosing in VTE(click here to see table)
    • UFH can be prescribed for patients with severe renal failure, and potentially unstable patients
      • Begin treatment with an initial bolus of 80 U/kg or to max 5000 U IV
      • Followed by an infusion of 18 U/kg/h or 1300 U/h
      • Fixed-dose and monitored regimens of subcutaneous UFH are available and are acceptable alternatives
      • Goal: rapidly achieving and maintaining the aPTT at levels that correspond to therapeutic heparin levels
  • DOAC dosing considerations
    • Since we do not dose adjust DOACs in patients with VTE, we need to be cognisant of patients in whom medication levels may vary:
      • extremes of weight (< 50 kg or > 120 kg)
      • elderly (age >80)
      • renal insufficiency (CrCl < 30mL/min)

Ultrasound is performed in ED the next day. You started a DOAC last night, leg swelling is worse and patient has more pain, and the proximal US is negative.

  • Stop the DOAC & order D-dimer test to rule out DVT
  • Key Point:
    • Generally speaking, the clinician will order a leg US to rule out DVT
    • Depending on the lab/radiologist, either a whole leg or proximal D/C US is done above knee (Proximal)
    • Below knee D/C US are not done in isolation
    • Guidelines recommend proximal US only

The D-Dimer test comes back as positive

  • No anticoagulation, but a follow-up proximal US should be repeated in 1 week
  • Patient should be followed up by primary care provider, a VTE specialist or ED follow-up clinic, depending on resources

References

  1. Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism (AMPLIFY). N Engl J Med. 2013;369(9):799-808. doi:10.1056/NEJMoa1302507.
  2. EINSTEIN Investigators, Bauersachs R, Berkowitz SD, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499-2510. doi:10.1056/NEJMoa1007903.
  3. EINSTEIN–PE Investigators, Büller HR, Prins MH, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012;366(14):1287-1297. doi:10.1056/NEJMoa1113572.
  4. Hokusai-VTE Investigators, Büller HR, Décousus H, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013;369(15):1406-1415. doi:10.1056/NEJMoa1306638.
  5. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic Therapy for VTE Disease. Chest. 2012;141(2 Suppl):e419S-e494S. doi:10.1378/chest.11-2301.
  6. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. CHEST. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026.
  7. Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism (PEITHO). New England Journal of Medicine. 2014;370(15):1402-1411. doi:10.1056/NEJMoa1302097.
  8. Righini M, Galanaud J-P, Guenneguez H, et al. Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. The Lancet Haematology. 2016;3(12):e556-e562. doi:10.1016/S2352-3026(16)30131-4.
  9. Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism (RE-COVER). N Engl J Med. 2009;361(24):2342-2352. doi:10.1056/NEJMoa0906598.
  10. Thrombosis Canada – Thrombose Canada | Dedicated To Furthering Education & Research in Thrombotic Disease. http://thrombosiscanada.ca/.
  11. Van Es J, Eerenberg ES, Kamphuisen PW, Büller HR. How to prevent, treat, and overcome current clinical challenges of VTE. J Thromb Haemost. 2011;9:265-274. doi:10.1111/j.1538-7836.2011.04334.x.
  12. Pfizer Canada Inc./BMS Canada. Eliquis (apixaban) Product Monograph, June 16, 2016.
  13. Bayer Inc. Xarelto (rivaroxaban) Product Monograph. September 1, 2016.
  14. Boehringer Ingelheim Canada Ltd. Pradaxa (dabigatran) Product Monograph. August 11, 2016.
  15. Servier Canada Inc. Lixiana (edoxaban) Product Monograph. January 12, 2017.

Suspected Pulmonary Embolism

  • 56 y/o female presents to ED with complaints of dyspnea and hemoptysis for 24 hours
  • No cough, chest or back pain
  • Past medical history:
    • Smoker: 1 pack per day for 30 years
    • Dyslipidemia, hypertension, post-menopausal, osteoarthritis
    • Post-op 2 weeks hysterectomy
    • Meds: atorvastatin, ASA (primary prevention), amlodipine
  • Examination
  • Actions

Discussion:

  • Guidelines state: anticoagulation should be started immediately* in patients with a Likely Pretest Probability of DVT/PE5 *applies only in patients with a low risk of bleeding
    • 2.2.1. In patients with a high clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment while awaiting the results of diagnostic tests (Grade 2C)
    • 2.2.2. In patients with an intermediate clinical suspicion of acute VTE, we suggest treatment with parenteral anticoagulants compared with no treatment if the results of diagnostic tests are expected to be delayed for more than 4 h (Grade 2C)
    • 2.2.3. In patients with a low clinical suspicion of acute VTE, we suggest not treating with parenteral anticoagulants while awaiting the results of diagnostic tests, provided test results are expected within 24 h (Grade 2C)
    • 1 Grade 2C: Weak recommendations, low grade evidence
    • Remarks: Initial parenteral anticoagulation is:
      • Given before dabigatran and edoxaban
      • Not given before rivaroxaban and apixaban

Treatment:

  • Patient has none of the factors indicated on the Simplified PESI Score, therefore she can be treated as an outpatient
  • Start patient on an anticoagulant for 3 months, follow-up with thrombosis clinic and or primary care physician, unless massive or submassive PE (see below)
  • Low risk PE =
    • Start anticoagulation and bring this patient back tomorrow to review the Angio-CT
    • Begin initial treatment for antithrombotic dosing in PE: (click here to see table)
      *UFH can be prescribed for patients with severe renal failure, and potentially unstable patients
    • Reconsider indication of concomitant antiplatelet medication
      • In this case, ASA is not indicated for primary prevention
      • Stopping ASA will reduce risk of bleeding for our patients

  • Submassive PE (SPE):
    • Evidence of new RV dysfunction by echo or CT but hemodynamically stable
    • Commonly used criteria for RV dysfunction include:
      • RV/LV ratio > 0.9 (echo or CT), or
      • RV hypo contractility
    • The use of biomarkers suggesting cardiac injury (elevated cTnI) or acutely elevated right pressures (BNP level) can help to stratify severity of pulmonary emboli
    • Consideration must be given to the possibility of preexisting right heart dysfunction when evaluating chamber sizes and BNP levels
    • A newly elevated BNP level is more significant in this context than a chronically elevated level
    • Expected mortality of SPE:
      • 4-30% based upon severity of RV dysfunction
  • Massive PE (MPE):
    • Any PE causing hemodynamic instability (systolic BP < 90 for greater than 15 mins or requiring pressor support of BP)
    • Expected mortality with MPE:
      • 70% when associated with cardiac arrest
      • 30% with ‘cardiogenic shock’
      • 15% with hypotension
  • Treatment of massive or submassive PE:
    • DOAC’s are not indicated, at least not in the emergency department
    • Consider unfractionated heparin, in case thrombolysis becomes warranted
    • Thrombolysis:
      • Indicated if patient unstable (Systolic blood pressure under 90 mmHg)
      • Submassive PE’s (no hypotension but right ventricular strain): Do not thrombolyse if they can be stabilised with anticoagulation treatment
      • Bleeding risk often outweighs the benefit of thrombolysis, although younger patients bleed less and may warrant special consideration
      • In case of hemodynamic decompensation, proceed to thrombolysis

References

  1. Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism (AMPLIFY). N Engl J Med. 2013;369(9):799-808. doi:10.1056/NEJMoa1302507.
  2. EINSTEIN Investigators, Bauersachs R, Berkowitz SD, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499-2510. doi:10.1056/NEJMoa1007903.
  3. EINSTEIN–PE Investigators, Büller HR, Prins MH, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012;366(14):1287-1297. doi:10.1056/NEJMoa1113572.
  4. Hokusai-VTE Investigators, Büller HR, Décousus H, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013;369(15):1406-1415. doi:10.1056/NEJMoa1306638.
  5. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic Therapy for VTE Disease. Chest. 2012;141(2 Suppl):e419S-e494S. doi:10.1378/chest.11-2301.
  6. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. CHEST. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026.
  7. Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for Patients with Intermediate-Risk Pulmonary Embolism (PEITHO). New England Journal of Medicine. 2014;370(15):1402-1411. doi:10.1056/NEJMoa1302097.
  8. Righini M, Galanaud J-P, Guenneguez H, et al. Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. The Lancet Haematology. 2016;3(12):e556-e562. doi:10.1016/S2352-3026(16)30131-4.
  9. Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism (RE-COVER). N Engl J Med. 2009;361(24):2342-2352. doi:10.1056/NEJMoa0906598.
  10. Thrombosis Canada – Thrombose Canada | Dedicated To Furthering Education & Research in Thrombotic Disease. http://thrombosiscanada.ca/.
  11. Van Es J, Eerenberg ES, Kamphuisen PW, Büller HR. How to prevent, treat, and overcome current clinical challenges of VTE. J Thromb Haemost. 2011;9:265-274. doi:10.1111/j.1538-7836.2011.04334.x.
  12. Pfizer Canada Inc./BMS Canada. Eliquis (apixaban) Product Monograph, June 16, 2016.
  13. Bayer Inc. Xarelto (rivaroxaban) Product Monograph. September 1, 2016.
  14. Boehringer Ingelheim Canada Ltd. Pradaxa (dabigatran) Product Monograph. August 11, 2016.
  15. Servier Canada Inc. Lixiana (edoxaban) Product Monograph. January 12, 2017.

Trauma on Anticoagulant with Prior DVT

  • 35 y/o female presents to ED on backboard and collar from an MVC
  • No LOC
  • EMS reports hypotension and tachycardia but GCS 15 on scene and en route
  • Medical history:
    • Hypertension
    • DVT 2 months ago, on treatment
    • Current medications:
      • “One of the new blood thinners, can’t remember the name” — taken 2 hours ago
      • BP pills”
  • Examination
  • Actions

Physical exam:

  • HR: 140 bpm; BP: 88/45 mmHg; Sat: 97%, GCS 15, CBS 5.5
  • Primary and secondary survey
  • Abdominal tenderness diffuse, no signs of basal skull fracture, no long bone tenderness, chest clear and no chest wall tenderness or crepitus, stable pelvis, log roll board removed
  • Bedside u/s: positive free fluid abdomen
  • Chest, pelvis and c-spine x-rays nil acute

Discussion:

Initial management

Treatment:

Reversal of DOACs in Emergency Situations
Initial Management

  • Interrupt anticoagulant therapy
  • Initiate resuscitation in a monitored setting
  • Initiate local hemostatic measures and refer for procedural/surgical intervention, if appropriate
  • Check hemoglobin concentration and platelet count to determine extent of blood loss and guide transfusion therapy (RBC transfusion for symptomatic anemia; platelet transfusion for thrombocytopenia or patients on antiplatelet agents)
  • Calculate CrCl and estimate half-life
  • Determine presence of NOAC-calibrated anti-Xa activity assay
  • If assay unavailable, use dosing regimen, timing of last dose & CrCl to determine presence of drug
  • If patient is on Rivaroxaban, Apixaban or Edoxaban:
    • Consider Pro-Hemostatic Therapy (No Clinical Evidence)
    • Prothrombin Complex Concentrate (PCC) (50 U/kg, max 3000 U)
      • OCTAPLEX® IV 1 mL/min followed by max 2-3 mL/min (180 mL/hr)
      • BERIPLEX® IV at 1 mL followed by max 8 mL/min (480 mL/hr)
    • Adjunctive therapy: Tranexamic acid 1g IV bolus then 1 g over 8 hrs
  • If patient is on Dabigatran
    • Idarucizumab 5g IV
    • Consider hemodialysis as an adjunctive option if massive overdose

Next Steps in Management

  • Proceed immediately to surgery or invasive procedure
  • Reintroduce anticoagulation appropriately after event, depending on patient’s thrombotic/bleeding risk
    • It is also recommended to determine the likely presence of drug and expected elimination rate using time of last dose, drug half-life and creatinine clearance (CrCl).
    • The estimated half-life for DOACs are:
      • Dabigatran: 7-17 h if CrCl ≥50 mL/min; 17-20 h if CrCl 30-49 mL/min
      • Rivaroxaban: 7-11 h if CrCl ≥50 mL/min; 7-11 h if CrCl 30-49 mL/min
      • Apixaban: 8-12 h if CrCl ≥50 mL/min; 8-12 h if CrCl30-49 mL/min

References

  1. Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism (AMPLIFY). N Engl J Med. 2013;369(9):799-808. doi:10.1056/NEJMoa1302507.
  2. EINSTEIN Investigators, Bauersachs R, Berkowitz SD, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499-2510. doi:10.1056/NEJMoa1007903.
  3. EINSTEIN–PE Investigators, Büller HR, Prins MH, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012;366(14):1287-1297. doi:10.1056/NEJMoa1113572.
  4. Hokusai-VTE Investigators, Büller HR, Décousus H, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013;369(15):1406-1415. doi:10.1056/NEJMoa1306638.
  5. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic Therapy for VTE Disease. Chest. 2012;141(2 Suppl):e419S-e494S. doi:10.1378/chest.11-2301.
  6. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. CHEST. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026.
  7. Righini M, Galanaud J-P, Guenneguez H, et al. Anticoagulant therapy for symptomatic calf deep vein thrombosis (CACTUS): a randomised, double-blind, placebo-controlled trial. The Lancet Haematology. 2016;3(12):e556-e562. doi:10.1016/S2352-3026(16)30131-4.
  8. Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism (RE-COVER). N Engl J Med. 2009;361(24):2342-2352. doi:10.1056/NEJMoa0906598.
  9. Thrombosis Canada – Thrombose Canada | Dedicated To Furthering Education & Research in Thrombotic Disease.
  10. Van Es J, Eerenberg ES, Kamphuisen PW, Büller HR. How to prevent, treat, and overcome current clinical challenges of VTE. J Thromb Haemost. 2011;9:265-274. doi:10.1111/j.1538-7836.2011.04334.x.
  11. Pollack CV, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015;373(6):511-520. doi:10.1056/NEJMoa1502000
  12. Di Franco A, Gaudino M, Girardi LN. Considerations about the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial. J Thorac Dis. 2016;8(7):E599. doi:10.21037/jtd.2016.05.43.
  13. Mahmood A, Roberts I, Shakur H. A nested mechanistic sub-study into the effect of tranexamic acid versus placebo on intracranial haemorrhage and cerebral ischaemia in isolated traumatic brain injury: study protocol for a randomised controlled trial (CRASH-3 Trial Intracranial Bleeding Mechanistic Sub-Study [CRASH-3 IBMS]). Trials. 2017;18. doi:10.1186/s13063-017-2073-6.
  14. Pfizer Canada Inc./BMS Canada. Eliquis (apixaban) Product Monograph, June 16, 2016.
  15. Bayer Inc. Xarelto (rivaroxaban) Product Monograph. September 1, 2016.
  16. Boehringer Ingelheim Canada Ltd. Pradaxa (dabigatran) Product Monograph. August 11, 2016.
  17. Servier Canada Inc. Lixiana (edoxaban) Product Monograph. January 12, 2017.

GI Bleed on Anticoagulant

  • 66 y/o male presents to ED feeling lightheaded, dizzy and weak with no SOB / no chest pain
  • EMS reports patient is hypotensive on scene and en route but no fluctuations
  • Started on DOAC for SPAF more than a year ago, now presents hypotensive, lightheaded, tachycardia with 7-day history of melena, and past 4 hours of bright red bleeding per rectum
  • Past medical history:
    • Hypercholesterolemia
    • GERD
    • Atrial Fibrillation
  • Current medications:
    • Pantoprazole
    • Simvastatin
    • “Blood thinner”
  • Examination
  • Actions
  • Physical exam
    • BP 99/50, HR 120-130 irregular, RR 24, Sats 95% RA, T37.1 celsius, glucometer 7.1
    • Patient appears slightly pale, alert and oriented x 3
    • Remainder of exam unremarkable, hemoccult positive
  • Initial management
    • Iv crystalloid fluid resuscitation wide open
    • Iv pantoprazole bolus and infusion started
    • Transfusion to maintain hemoglobin >70g/L during active bleeding
  • Additional information becomes available during management
    • Hemoglobin 63
  • After 2L n/s bolus: BP 100/55, HR 110

Discussion:

Canadian Cardiovascular Society Atrial Fibrillation Guidelines (2016) – When to Interrupt Antithrombotic Therapy 1

  • For patients with AF or atrial flutter on antithrombotic therapy
    • Interrupting for an invasive procedure must balance the risks of a thromboembolic event (as indicated by a higher CHADS2 score, mechanical heart valve, or rheumatic heart disease) with those of a bleeding event (as indicated by a higher HASBLED score and procedures with higher bleeding risks)
    • Is not necessary for most procedures with a very low risk of bleeding and many procedures with a low risk of bleeding, including cardiac device implantation (pacemaker or implantable defibrillator)
    • Will be necessary for most procedures with an intermediate or high risk of major bleeding (e.g. neurosurgery, lung resection, kidney biopsy, etc. )
    • Tool: Thrombosis Canada’s Bleed Acute Management Algorithm

Treatment:

  • Severe/life-threatening (e.g. ICH, critical site, hemodynamic compromise, Hb decrease ≥20 g/L or of ≥2 units RBCs) (click here for management of minor or moderate bleeding – see below)
    • Resuscitation and discontinue warfarin
    • Local measures and referral for definitive treatment
    • Reverse warfarin (if this is OAC) if INR >1.5: Vitamin K 10 mg IV and PCC as per INR and weight (kg)*
    • Reverse DOAC as indicated: Idarucizumab 5g iv if Dabigatran; if any other DOAC, no evidence based reversal available yet. Recommendation to give PCCand tranexamic acid
    • Transfuse to maintain Hb >70 g/L and platelet count >50–100×109/L
    • CBC: complete blood count; INR: international normalized ratio; SSRI: selective serotonin reuptake inhibitors; NSAIDs: non-steroidal anti-inflammatory drugs;PCC: prothrombin complex concentrate; IV: intravenous; Hb: hemoglobin; GI: gastrointestinal; RBCs: red blood cells
    • *PCC dosing is not weight based in Canada

  • Minor bleeding (e.g. anterior epistaxis, hemorrhoid bleeding, minor subconjunctival bleed) 2
    • Continue anticoagulant
    • Confirm appropriate drug and dose based on indication, age, weight, CrCl
    • Consider checking Hb, platelet count and renal function to see if stable
  • Moderate bleeding (e.g. hemodynamically stable GIbleed, major epistaxis, hematuria)
    • Hold DOAC
    • Determine cause of bleeding
    • Local hemostasis (compression, packing) if applicable
    • Obtain CBCPT/INRPTT, creatinine
    • Determine likely presence of drug and expected elimination rate
    • If available, determine plasma concentration of DOACusing validated assay
    • Transfusion therapy should be given as per standard supportive measures
    • Consultation if indicated

References

  1. Macle L, Cairns J, Leblanc K, et al. 2016 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Canadian Journal of Cardiology. 2016;32(10):1170-1185. doi:10.1016/j.cjca.2016.07.591.
  2. Thrombosis Canada – Thrombose Canada | Dedicated To Furthering Education & Research in Thrombotic Disease.
  3. Pollack CV, Reilly PA, Eikelboom J, et al. Idarucizumab for Dabigatran Reversal. N Engl J Med. 2015;373(6):511-520. doi:10.1056/NEJMoa1502000
  4. Di Franco A, Gaudino M, Girardi LN. Considerations about the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial. J Thorac Dis. 2016;8(7):E599. doi:10.21037/jtd.2016.05.43.
  5. Mahmood A, Roberts I, Shakur H. A nested mechanistic sub-study into the effect of tranexamic acid versus placebo on intracranial haemorrhage and cerebral ischaemia in isolated traumatic brain injury: study protocol for a randomised controlled trial (CRASH-3 Trial Intracranial Bleeding Mechanistic Sub-Study [CRASH-3 IBMS]). Trials. 2017;18. doi:10.1186/s13063-017-2073-6.
  6. Pfizer Canada Inc./BMS Canada. Eliquis (apixaban) Product Monograph, June 16, 2016.
  7. Bayer Inc. Xarelto (rivaroxaban) Product Monograph. September 1, 2016.
  8. Boehringer Ingelheim Canada Ltd. Pradaxa (dabigatran) Product Monograph. August 11, 2016.
  9. Servier Canada Inc. Lixiana (edoxaban) Product Monograph. January 12, 2017.

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