Assessing the management of major bleeding events in patients treated by direct oral anticoagulant in an emergency department.

Since direct oral anticoagulants have been marketed, the management of major bleeding in emergency departments has become more challenging. In 2013 and 2016, the Working Group in Perioperative Haemostasis made several proposals for this. The objective of the present study was to evaluate conformity with these proposals in daily clinical practice. We performed a retrospective single-center cohort study addressing the management of major bleeding in patients treated by direct oral anticoagulant in an emergency department. Patients were included between January 1, 2015 and November 30, 2017. Among 3,365 patients admitted to the emergency department for bleeding, a total of 191 were treated by direct oral anticoagulant and 55 (28.8%) with major bleeding were included in the present study. The majority of patients received rivaroxaban (n = 44, 80.0%) and were treated for atrial fibrillation (n = 47, 85.0%). Bleeding concerned gastrointestinal (n = 30, 54.6%) and (n = 14, 25.5%) intracranial location. Twenty-one patients (38.2%) were treated by prothrombin complex concentrate, and 31 patients (56.4%) were transfused. Intervention for hemostatic control was performed for 30 patients (54.6%). Thirty-three patients (60.0%) presented a deviation from protocol. There is no significant difference for mortality at 3 months according to whether or not there was a deviation from protocol. Nearly two-thirds of patients with major bleeding associated with direct oral anticoagulant administration had protocol deviation, but there was no effect on mortality.