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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.


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


Charles Pollack
Thomas Jefferson University Hospital, Philadelphia, USA