Management of Hemorrhage Complicated by Novel Oral Anticoagulants in the Emergency Department: Case Report From the Northwestern Emergency Medicine Residency Amy Kiraly, MD, 1 Abbie Lyden, PharmD, 2,3 Usha Periyanayagam, MD, MPH, MS, 1 Jennifer Chan, MD, MPH, 1 and Peter S. Pang, MD 1,4,5 * Anticoagulation has long complicated the care of hemorrhage in the emergency department and other acute care settings. With the advent of novel anticoagulants such as direct thrombin inhibitors and direct factor Xa inhibitors, the absence of any direct antidote for these medications presents new and difficult challenges in the management of hemorrhagic complications in these patients. We present 2 cases of patients with hemorrhagic complications taking novel oral anticoagulants, their management, and outcomes. Keywords: hemorrhage, prothrombin complex concentrates, rivaroxaban, dabigatran, FEIBA, anticoagulation Anticoagulation has long complicated the care of hem- orrhage in the emergency department (ED) and other acute care settings. With the advent of novel anticoagu- lants such as direct thrombin inhibitors and direct factor Xa inhibitors, the absence of any direct antidote for these medications presents new and difficult challenges in the management of hemorrhagic complications in these patients. We present 2 cases of patients with hem- orrhagic complications taking novel oral anticoagulants, their management, and outcomes. Dr Amy Kiraly: A 69-year-old man was brought to the ED for altered mental status. He had a medical his- tory significant for coronary artery disease, atrial fibril- lation, and multiple recent surgeries including low lumbar spine laminectomy, bilateral L-S foraminotomies, and right microdiskectomy. That same morning, the patient had a regularly scheduled postoperative follow- up appointment. As he was leaving the appointment, he became acutely diaphoretic, confused, and complained of a headache. Per his caregiver, the patient was in his usual state of health until this acute event. The patient reported that at the onset of his pain, he felt like his head “was going to explode” and stated he never had a similar headache in the past. At presentation, the patient was slightly confused, and therefore, it was difficult to elicit a complete history. He reported that he still had a dull frontal headache, but that it had improved significantly since onset. There was no report of falls or other trauma. In the ED, he was afebrile, with a heart rate of 78, with a blood pressure of 141/82, and with an oxygen saturation of 99% on room air. He was alert and non- toxic appearing. Focused review of systems revealed no focal weakness, numbness, tingling, chest pain, or short- ness of breath. His medical history was notable for chronic kidney disease, coronary artery disease, atrial fibrillation, chronic obstructive pulmonary disease, and hypertension. His surgical history was notable for a coronary artery bypass graft and the spinal surgery 1 Department of Emergency Medicine, Northwestern University Feinberg School of Medicine; 2 Northwestern Memorial Hospital; 3 Rosalind Franklin University of Medicine and Science; 4 Depart- ment of Medicine, Center for Cardiovascular Innovation; and 5 Institute for Public Health and Medicine, Chicago, IL. The authors have no conflicts of interest to declare. *Address for correspondence: 211 E Ontario St, Suite 300, Chicago, IL 60611. E-mail: ppang@northwestern.edu American Journal of Therapeutics 20, 300–306 (2013) 1075–2765 Ó 2013 Lippincott Williams & Wilkins www.americantherapeutics.com