Owing to the propensity of anticoagulated patients to bleed, a strategy for reversal of anticoagulation induced by any of the common agents is essential. Many patients are anticoagulated with a variety of agents, including warfarin, low molecular weight heparin, and the direct oral anticoagulants such as factor Xa and factor IIa inhibitors. Patients may also be using antiplatelet agents. Recommendations to reverse bleeding in these patients are constantly evolving with the recent development of specific reversal agents. A working knowledge of hemostasis and the reversal of anticoagulation and antiplatelet drugs is required for every emergency department provider. This article reviews these topics and presents the currently recommended strategies for dealing with bleeding in the anticoagulated patient.

ABSTRACT: Audience: This scenario was developed to educate emergency medicine residents on the diagnosis and management of acute hemolytic transfusion reactions in the emergency department. The case is appropriate for senior medical students and advanced practice providers. The principles of crisis resource management, teamwork, and communication are also incorporated into the case.

Introduction: Patients who present with suspected acute hemolytic transfusion reactions require rapid diagnosis and management, as well as a thorough evaluation for other differential diagnoses, such as DIC (disseminated intravascular coagulation), TTP (thrombotic thrombocytopenic purpura), and sepsis. The possibility of acute hemolytic transfusion must be entertained early, as it carries significant morbidity including the risk of developing acute hemolytic anemia, acute renal failure, DIC, shock, and/or death.1 The mortality rate of acute hemolytic transfusion reactions can reach 44%, and it accounts for 20% of all transfusion-related mortalities.2,3 Given this significant morbidity and mortality, early recognition and management are paramount in the emergency department (ED) to avoid clinical deterioration and death.

Objectives: By the end of this simulation session, the learner will be able to: 1) Recognize the clinical signs and symptoms associated with transfusion reactions. 2) Discuss necessary systems-based management of potential transfusion reactions, such as notifying the blood bank and evaluating to see if another patienta accidentally received a wrong unit of blood. 3) Discuss the management of various transfusion reactions. 4) Appropriately disposition the patient to an intensive care unit (ICU) or stepdown unit. 5) Effectively communicate with team members and nursing staff during the resuscitation of a critically ill patient.

Method: This session is conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis and management of transfusion reactions. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques.

Topics: Medical simulation, acute hemolytic transfusion reaction, transfusion reactions, hematology, emergency medicine.