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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.

The recent emergence of 'non-VKA' oral anticoagulants may have led to some forgetting that vitamin K antagonists (VKA) are by far the most widely prescribed oral anticoagulants worldwide. Consequently, we decided to summarize the information available on them. This paper presents the problems facing emergency physicians confronted with patients on VKAs in 10 points, from pharmacological data to emergency management. Vitamin K antagonists remain preferable in many situations including in the elderly, in patients with extreme body weights, severe chronic kidney or liver disease or valvular heart disease, and in patients taking VKAs with well-controlled international normalized ratios (INRs). Given the way VKAs work, a stable anticoagulant state can only be achieved at the earliest 5 days after starting therapy. The induction phase of VKA treatment is associated with the highest risk of bleeding; validated algorithms based on INR values have to be followed. VKA asymptomatic overdoses and 'non-severe' hemorrhage are managed by omitting a dose or stopping treatment plus administering vitamin K depending on the INR. Major bleeding is managed using a VKA reversal strategy. A prothrombin complex concentrate infusion plus vitamin K is preferred to rapidly achieve an INR of up to 1.5 and maintain a normal coagulation profile. The INR must be measured 30 min after the infusion. Before an invasive procedure, if an INR of less than 1.5 (<1.3 in neurosurgery) is required, it can be achieved by combining prothrombin complex concentrate and vitamin K. A well-codified strategy is essential for managing patients requiring emergency invasive procedures or presenting bleeding complications.

Viscoelastic technics are used for 10 years and include the ROTEM ® and the TEG ® . These devices that exploit the viscoelastic properties of the clotting blood, allow a rapid and global analysis of the haemostatic process taking into account all the process interfering with haemostasis such as inflammation. It has been shown that the use of these technics in clinical situations such as trauma, postpartum haemorrhage, gastrointestinal bleeding or cardiac surgery may reduce the need for blood product, the cost and perhaps may improve the outcome of the patients. Thanks to a rapid identification of the underlying coagulation deficit, these technics facilitate decision-making during acute care and help to guide the treatment, particularly with coagulation factor's concentrate., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Introduction: In vitamin K antagonist (VKA)-treated patients with severe hemorrhage, guidelines recommend prompt VKA reversal with prothrombin complex concentrate (PCC) and vitamin K. The aim of this observational cohort study was to evaluate the impact of guideline concordant administration of PCC and vitamin K on seven-day mortality., Methods: Data from consecutive patients treated with PCC were prospectively collected in 44 emergency departments. Type of hemorrhage, coagulation parameters, type of treatment and seven-day mortality mortality were recorded. Guideline-concordant administration of PCC and vitamin K (GC-PCC-K) were defined by at least 20 IU/kg factor IX equivalent PCC and at least 5 mg of vitamin K performed within a predefined time frame of eight hours after admission. Multivariate analysis was used to assess the effect of appropriate reversal on seven-day mortality in all patients and in those with intracranial hemorrhage (ICH)., Results: Data from 822 VKA-treated patients with severe hemorrhage were collected over 14 months. Bleeding was gastrointestinal (32%), intracranial (32%), muscular (13%), and "other" (23%). In the whole cohort, seven-day mortality was 13% and 33% in patients with ICH. GC-PCC-K was performed in 38% of all patients and 44% of ICH patients. Multivariate analysis showed a two-fold decrease in seven-day mortality in patients with GC-PCC-K (odds ratio (OR) = 2.15 (1.20 to 3.88); P = 0.011); this mortality reduction was also observed when only ICH was considered (OR = 3.23 (1.53 to 6.79); P = 0.002)., Conclusions: Guideline-concordant VKA reversal with PCC and vitamin K within eight hours after admission was associated with a significant decrease in seven-day mortality.

Introduction: Prothrombin complex concentrate (PCC) for reversal of vitamin K antagonist (VKA) is the main therapeutic option in cases of life-threatening bleeding. Clinical use of PCC is poorly documented., Methods: We prospectively assessed PCC use in four French emergency departments during a two year period 2006-2008 before publication of French Guidelines. An appropriate treatment was defined when PCC was recommended, with a dose of PCC above or equal to 20 UI/kg, with vitamin K and with an assessment of international normalized ratio (INR) after PCC. Time of diagnosis and PCC administration were collected, as INR values, thromboembolic events within seven days, hospital mortality., Results: 256 patients received PCC for reversal of OAT. PCC was mainly prescribed for major intracerebral (ICH) or gastrointestinal hemorrhage. An appropriate treatment was observed in 26% of patients. Intra-hospital mortality for major bleeding was 33% for ICH and 26% for non-ICH major bleeding. A PCC dose>20 UI/kg was able to reach an INR<1.5 in 65% of patients. For major hemorrhages (70%), time between patient arrival and treatment delivery exceeded three hours in half of cases. Control of INR was omitted in 20% of patients. No patients presented a thromboembolic event., Conclusion: A suitable treatment was administered in 26% of patients. A PCC dose of 20-30 IU/kg seems adequate in most cases to reverse VKA activity, but both higher and lower doses achieve similar effects. Considerable progress is required to improve PCC administration and control of treatment efficacy, and to shorten time to diagnosis., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To assess compliance and impact of a teaching program on guidelines for the management of severe bleeding under oral anticoagulation therapy in emergency departments (EDs)., Design and Setting: Multicenter, before-after observational studies in six French EDs., Patients: Forty-five patients in 2003 and 54 patients in 2005 consecutively admitted with severe bleeding under oral anticoagulation therapy., Interventions: A specific teaching program on management of severe bleeding under oral anticoagulation therapy, performed by an expert physician., Measurements and Results: Primary end-point was the use of prothrombin complex concentrate-vitamin K association between the two study periods. Nine patients (20%) in 2003 and 29 patients (54%) in 2005 received this association (P < 0.01). Almost one-third of patients had only withholding oral anticoagulation therapy. Adverse events and mortality rate did not differ between the two phases., Conclusions: Compliance with guidelines on the management of severe bleeding under oral anticoagulation remains poor and might be improved by specific teaching program.

Abstract: Objective: The purpose of this review is to present the progressive extension of the concept of damage control resuscitation, focusing on the prehospital phase. Article type: Review of the literature in Medline database over the past 10years. Data source: Medline database looking for articles published in English or in French between April 2002 and March 2013. Keywords used were: damage control resuscitation, trauma damage control, prehospital trauma, damage control surgery. Original articles were firstly selected. Editorials and reviews were secondly studied. Data synthesis: The importance of early management of life-threatening injuries and rapid transport to trauma centers has been widely promulgated. Technical progress appears for external methods of hemostasis, with the development of handy tourniquets and hemostatic dressings, making the crucial control of external bleeding more simple, rapid and effective. Hypothermia is independently associated with increased risk of mortality, and appeared accessible to improvement of prehospital care. The impact of excessive fluid resuscitation appears negative. The interest of hypertonic saline is denied. The place of vasopressor such as norepinephrine in the early resuscitation is still under debate. The early use of tranexamic acid is promoted. Specific transfusion strategies are developed in the prehospital setting. Conclusion: It is critical that both civilian and military practitioners involved in trauma continue to share experiences and constructive feedback. And it is mandatory now to perform well-designed prospective clinical trials in order to advance the topic. [Copyright &y& Elsevier]