In part 2 of this 4-part series. Dr. Baugh discusses the How, When and Why: Utilizing a Reversal Agent
Faculty: Christopher Baugh, MD, MBA
Vice Chair of Clinical Affairs Department of Emergency Medicine | Brigham and Women's Hospital Associate Professor | Harvard Medical School
Dr. Baugh has published on the clinical and administrative aspects of observation care in the New England Journal of Medicine, Health Affairs, Annals of Emergency Medicine, and Academic Emergency Medicine. He previously served as Chair of the Observation Medicine Section of the American College of Emergency Physicians
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- Now let's talk about the key considerations for giving an anticoagulated patient a reversal agent. Each ED will have reversal agents on formulary. Some reversal agents are very specific for a particular blood thinner, and others are not specific, but contain factors that are impaired by the anticoagulant, so they act by replacing those factors. You should be familiar with which treatments are locally available in your institution. Since these treatments can be costly and have risks associated with them, most hospitals have a policy in place around when they can be ordered and whether approval is needed. You should know how to order these treatments and navigate approvals in real time 24/7, to avoid unnecessary delays. You should also be familiar with common dosing scenarios and leverage your electronic medical record to make ordering simple. The two primary scenarios for anticoagulant reversal in the ED are first, life-threatening bleeding, and then second, critical site bleeding. We can define life-threatening bleeding, as usually a GI source or large compartment, such as the retroperitoneum. While this may be more specifically defined in your local reversal policy, some also defer to emergency physician judgment alone. Some examples of specific criteria include a large hemoglobin drop plus transfusion, or uncontrolled bleeding requiring procedural intervention, or bleeding that requires intravenous vasoactive agents. Next, we can define critical site bleeding, as most commonly the brain, but it's also helpful to think of a few other areas of the body that could be considered critical, such as the eye, spine, airway, pericardium, aorta, or any close space with concern for compartment syndrome. We give reversal agents to restore hemostasis and the patient's underlying function of the coagulation cascade, reduce the rate of ongoing bleeding, prevent the expansion of bleeding in a critical site, and give time for proceduralists to obtain source control to help stabilize the patient. Reversal also may be helpful to buy time for diagnostic testing, transfer, and other interventions. Finally, don't forget to perform your usual stabilizing efforts in addition to reversal such as blood product administration and other key elements of resuscitation.
