Managing a patient on NOACs in the emergency room setting

Join Dr Charles Pollack describing the course of action for an 85-year-old anticoagulated patient, who had broken her hip and presented to the emergency room (ER) requiring urgent surgery.

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Charles Pollack

Thomas Jefferson University Hospita

Philadelphia, USA


In this video, Dr Charles Pollack presents the case of a patient with a fractured hip who is suspected to be receiving anticoagulation. It is initially unknown which agent she is taking and the importance of avoiding surgical delays is emphasised.

While the prescribed anticoagulant is being determined, initial investigations to assess bleeding risks in this time-sensitive situation are carried out and considered.

The different anticoagulation reversal strategies are discussed in the event of the patient being prescribed either: a vitamin K antagonist (VKA); a factor IIa non-vitamin K antagonist oral anticoagulant (NOAC); or a factor Xa NOAC.

After patient history investigations find that she is taking dabigatran (a factor IIa NOAC), the appropriate reversal agent – in this case idarucizumab – is administered before performing surgery. There follows a discussion of the RE-VERSE AD trial which enabled the approval of idarucizumab for dabigatran reversal.

  • Target audience
    This educational activity is designed for hospitalists, haematologists, interventional cardiologists, internists/physicians, emergency physicians, surgeons and any other healthcare professional with an interest or role in the management of patients on anticoagulation and requiring reversal.
  • Learning objectives
    After completing this educational activity, participants should be able to:
    • Recognise the importance of determining the anticoagulant status of a patient requiring urgent surgery
    • Select the appropriate anticoagulation reversal strategy for an anticoagulated patient presenting to the accident and emergency department with major bleeding, or requiring emergency surgery
    • Recall that idarucizumab is the appropriate reversal agent to use in a patient requiring urgent surgery who is anticoagulated with dabigatran
  • Disclosures
    Dr Charles Pollack, Thomas Jefferson University, Philadelphia, USA
    • Receipt of grants/research supports: Janssen, Portola, Boehringer Ingelheim, Daiichi Sankyo, CSL Behring
    • Receipt of consultation fees: Janssen, Portola, Boehringer Ingelheim, BMS/Pfizer
    Dr Felix Chapovsky (TBC)

    Staff and reviewer disclosures

    PCM Scientific staff, and others involved with the planning, development, and review of the content for this activity have no relevant affiliations or financial relationships to disclose.
  • Funding
    This independent educational activity is supported by funding from Boehringer Ingelheim. PCM Scientific is the medical education company acting as scientific secretariat and organiser for this programme. The activity is run independently of the financial supporter and all content is created by the faculty. No funder has had input into the content of the activity.