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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Bleeding while anticoagulated

Haematology and transfusion · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Critical-site or haemodynamic haemorrhage

Intracranial, spinal, pericardial, retroperitoneal or airway bleeding, shock, ongoing transfusion requirement or uncontrolled anatomical loss requires immediate resuscitation, reversal assessment and source control.

Action: Stop anticoagulants and unnecessary antiplatelets, activate major-haemorrhage care, obtain drug, dose, last-time, FBC, renal, liver, coagulation, fibrinogen and group information, involve haematology and the source-control specialty, then give the indicated specific or factor replacement without waiting for deterioration.

Synopsis

Assess bleeding severity and residual anticoagulant effect, restore physiology and source control, choose proportionate reversal and make a deliberate thrombosis-safe restart plan.

  • Classify the clinical bleed first: critical site, haemodynamic compromise, uncontrolled loss or substantial transfusion need makes it major regardless of the laboratory result.
  • Stop anticoagulant and unnecessary antiplatelets, resuscitate, correct temperature and calcium, and obtain source control; reversal alone cannot close a vessel or treat a lesion.
  • Record exact drug, indication, dose, last dose time, renal trajectory, weight and interacting medicines before exposure information is lost during transfer.
  • Warfarin major bleeding: four-factor PCC using the stocked product schedule plus 5–10 mg slow IV phytomenadione.
  • Dabigatran major bleeding: idarucizumab 5 g IV as two consecutive 2.5 g doses; assess rebound especially in overdose or renal failure.
  • Apixaban or rivaroxaban life-threatening or uncontrolled bleeding: consider andexanet within its licence and current NICE/local access, or specialist off-label PCC when specific reversal is inappropriate.
  • UFH bleeding: stop infusion and give slow IV protamine from recent exposure; LMWH is only partially reversed and fondaparinux has no specific antidote.
  • Do not transfuse platelets for a normal count merely because aspirin or a DOAC was taken; target thrombocytopenia, a procedural threshold or a specialist antiplatelet strategy.
  • Routine tranexamic acid is not supported for gastrointestinal bleeding; use it promptly for qualifying trauma under the major-trauma regimen and for other indications according to their evidence.
  • Make the restart decision daily once haemostasis is secure, with site, source, indication, time since thrombosis, renal function and patient priorities documented.

Key red flags

New focal neurology, severe headache, reduced consciousness or significant head trauma demands immediate CT and anticoagulant reversal assessment even without shock.

Hypotension, tachycardia, syncope, rising lactate, oliguria or continued haemoglobin fall indicates physiologically major bleeding and should activate a major-haemorrhage response.

Airway bleeding, spinal cord symptoms, tense limb swelling, severe abdominal or back pain or pericardial compromise can be fatal from pressure at a small blood volume.

Recent VTE, mechanical mitral valve, triple-positive APS or very high-risk AF creates substantial restart urgency once haemostasis is achieved; reversal is not a permanent treatment decision.

Critical anatomy

Neurology, airway compromise, cord symptoms, tamponade, retroperitoneal pain or a tense compartment requires emergency action before large-volume loss is visible.

Investigation priorities

01
First-line: FBC, group, renal and liver profileFirst stepFirst line

Assess loss, reserve, clearance and transfusion readiness.

Management branches

Major bleedStabilise, reverse and control source

Bleeding is critical-site, haemodynamic, uncontrolled or requires major transfusion.

  1. Stop antithrombotics, activate ABCDE and major-haemorrhage care, obtain exposure and laboratory data and call the anatomical source-control team.
  2. Give drug-specific reversal or factor replacement using the warfarin, dabigatran, factor-Xa or heparin branch while correcting temperature, calcium and component deficits. For the factor-Xa branch, obtain urgent specialist selection: BSH 2026 warns that andexanet-associated thromboembolic risk, particularly ischaemic stroke, may outweigh benefit.
  3. Confirm clinical haemostasis and source treatment, watch for thrombosis and start a daily restart assessment.

Key medicines

Warfarin reversalFor major bleeding give four-factor PCC using the stocked product's INR and weight table plus phytomenadione 5–10 mg by slow IV injection; for INR above 8 without bleeding use 1–5 mg oral phytomenadione and prompt recheck.PCC is thrombotic and should not be routine for non-bleeding INR elevation. Use product maximums, give vitamin K with emergency PCC, reassess INR and haemostasis and avoid automatic redosing without senior review.
IdarucizumabGive 5 g intravenously as two consecutive 2.5 g/50 mL doses for dabigatran-associated life-threatening or uncontrolled bleeding or urgent surgery that cannot wait.It does not reverse factor Xa inhibitors. Monitor recurrent bleeding and assay rebound in severe renal impairment or overdose, watch thrombosis and consider repeat 5 g only for SmPC-supported clinical recurrence.
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Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG39 major trauma recommendationsMajor-haemorrhage organisation and adult trauma tranexamic acid regimen.
  • MHRA DOAC bleeding and reversal reminderUK agent-specific reversal safety advice.
  • NICE TA697 andexanet alfa recommendationsNICE's defined gastrointestinal-bleeding recommendation and commercial-arrangement condition.
  • Beriplex Summary of Product CharacteristicsWarfarin reversal dosing and PCC safety.
  • NICE NG158 VTE recommendationsThrombotic indication, treatment duration and ongoing review.
  • BSH position statement on andexanet alfa, April 2026Current UK warning that thromboembolic risk, particularly ischaemic stroke, may outweigh benefit.
  • Ondexxya current UK Summary of Product CharacteristicsMarch 2026 text: licensed population, low/high dosing tables, no dose recommendation for unknown last dose amount or interval, and safety limitations.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·

Content changes
Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom