Critical Issue Related to Direct Oral Anticoagulants in Adult Patients Presenting to the Emergency Department

2026 guideline from the American College of Emergency Physicians.

These guideline summaries are shared for educational purposes only and are not intended to direct patient care. For detail on the specific recommendations and information about the evidence considered by the guideline developer, we encourage you to go to the original guideline statement cited below.

Strength

Adult ED and ICU Patients with Acute Major Bleeding and Taking a DOAC

Treatment

Level C

In adult ED patients on dabigatran with acute major symptomatic bleeding, idarucizumab may be considered and should be weighed against potential risk of thrombotic events.

Level C

In adult ED patients on factor Xa inhibitors with acute major symptomatic bleeding, usual care including four-factor PCC may be considered. Outside the United States where andexanet alfa remains available, its use may be considered after weighing uncertain outcome-centered benefit, thrombotic risk, and cost (Consensus recommendation).

Level C

Shared decision making with patients or surrogate decision makers may be helpful to frame potential benefits and risks of any acute anticoagulation reversal (Consensus recommendation).

Literature

Original/Primary Reference

Tomaszewski C et al. Clinical Policy: A Critical Issue Related to Direct Oral Anticoagulants in Adult Patients Presenting to the Emergency Department Annals of Emergency Medicine, 88, e15-e33

What do the ratings mean?

Level A

Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B

Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).

Level C

Other strategies for patient management that are based on Class III studies or, in the absence of any adequate published literature, based on panel consensus. In instances in which consensus recommendations are made, this is specifically indicated next to the recommendation.