What should be done for a patient with a large bruise to the left axilla who is on anticoagulant medication?

Management of Large Axillary Bruise in Anticoagulated Patient

Stop the anticoagulant immediately and apply local compression to the axilla, as this represents a non-major bleeding event that requires anticoagulation interruption but not reversal agents. 1

Initial Assessment of Bleeding Severity

First, determine if this meets criteria for major bleeding by checking for any of the following 1:

• Bleeding at a critical site (axilla is NOT considered critical)
• Hemodynamic instability
• Hemoglobin decrease ≥2 g/dL
• Need for ≥2 units of packed red blood cells

If none of these criteria are present, this is classified as non-major bleeding. 1

Immediate Management for Non-Major Axillary Bleeding

Since the axilla is not a critical bleeding site and assuming the patient is hemodynamically stable 1:

• Stop the oral anticoagulant immediately 1
• Apply local compression and manual pressure to the axilla 1, 2
• Provide supportive care and volume resuscitation as needed 1
• If applicable, stop any concomitant antiplatelet agents 1

Specific Anticoagulant Management

For patients on warfarin (VKA): Consider administering 2-5 mg vitamin K (oral or IV) 1

For patients on DOACs (dabigatran, rivaroxaban, apixaban): Do NOT administer reversal agents for non-major bleeding 1

Laboratory Evaluation

Obtain the following studies 3:

• Complete blood count to assess hemoglobin and hematocrit
• Coagulation studies (PT/INR if on warfarin, aPTT if on heparin)
• Assess for comorbidities contributing to bleeding (thrombocytopenia, uremia, liver disease) 1

Critical Pitfall to Avoid

Do not continue anticoagulation for non-major bleeding at non-critical sites. The 2020 ACC guidelines clearly state that non-major bleeding requires stopping anticoagulation, even though reversal agents are not indicated. 1 This differs from truly minor bleeding (small superficial wounds) where continuation may be considered. 2

When to Consider Major Bleeding Management

Escalate to major bleeding protocols if 1:

• The bruise expands rapidly suggesting active hemorrhage
• Hemoglobin drops ≥2 g/dL
• Patient develops hemodynamic instability
• Compartment syndrome develops (rare but possible in axilla)

In these scenarios, administer specific reversal agents: vitamin K 5-10 mg IV plus prothrombin complex concentrates for warfarin, or idarucizumab for dabigatran or andexanet alfa for apixaban/rivaroxaban. 1, 4

Restarting Anticoagulation

Once bleeding is controlled and the patient is stable, assess the following factors before restarting 1:

Delay or discontinue anticoagulation if 1:

• High risk of rebleeding
• Source of bleeding not identified
• Surgical procedures planned
• Patient preference against restarting

Restart anticoagulation if 1:

• Bleeding source identified and controlled
• Strong indication for anticoagulation exists (e.g., mechanical valve, atrial fibrillation with high stroke risk)
• No high-risk features for rebleeding present

For patients with high thrombotic risk, consider restarting at 48 hours to 7 days depending on bleeding severity and thrombotic risk stratification. 5