5.4. Managing Major Bleeds
Anticoagulants and antiplatelet agents should be held and airway and large-bore intravenous access secured. Reversal of OAC is recommended if an agent is available for most patients with major bleeding (see section on OAC Reversals), but obtaining and administering the reversal agent must not delay resuscitation and local hemostatic measures. For patients with ongoing bleeding and/or hemodynamic instability, local measures to control bleeding (e.g., pressure, packing) should be combined with volume resuscitation.
At this time, there is limited evidence to support routine administration of platelets in the setting of antiplatelet agent use (e.g., aspirin, P2Y12 inhibitors). Two systematic reviews of small studies concluded that there was no benefit of such therapy for patients with an intracranial hemorrhage (42,43). Additionally, a more recent trial that randomized patients with intracranial hemorrhage and on antiplatelet therapy to platelet transfusion found higher odds of death or dependence among the platelet transfusion group (44). As such, the writing committee does not recommend routine administration of platelets for patients who are bleeding and on antiplatelet agents, although this can be considered in specific cases, particularly after other measures such as reversal of OAC have failed.
5.5. Managing Nonmajor Bleeds
Irrespective of the severity, local measures should be employed where possible to control any bleeding. For patients with a nonmajor bleed, we do not recommend routine reversal of the OAC, although it is often advisable to temporarily discontinue OAC therapy until the patient is clinically stable and hemostasis has been achieved.
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