What is the best course of action for a patient with a 6.3 cm anechoic structure in the right calf, likely a hematoma, who is currently taking Eliquis (apixaban) for anticoagulation?

Management of 6.3 cm Calf Hematoma in Patient on Apixaban

Temporarily discontinue apixaban and assess for hemodynamic stability, compartment syndrome, and need for reversal based on bleeding severity. 1

Immediate Assessment and Risk Stratification

Determine Bleeding Severity

• Assess for major bleeding criteria: hemodynamic instability (systolic BP <90 mmHg, heart rate >100 bpm), drop in hemoglobin ≥2 g/dL, need for transfusion of ≥2 units packed red blood cells, or bleeding in a critical anatomical site 1
• Evaluate for compartment syndrome: severe pain disproportionate to examination, pain with passive stretch, paresthesias, palpable tenseness of the compartment, and diminished distal pulses 1
• Check renal function: creatinine clearance determines apixaban half-life (6-15 hours with normal renal function, up to 17 hours with severe impairment), which impacts duration of anticoagulant effect 1

Classify the Bleeding Event

This 6.3 cm hematoma likely represents major bleeding given its size, requiring temporary discontinuation of apixaban and consideration of reversal strategies 1

Anticoagulation Management

Discontinue Apixaban Immediately

• Stop apixaban at least temporarily until bleeding risk is controlled 1
• The drug effect will dissipate over 2-3 half-lives (approximately 12-30 hours depending on renal function) without reversal 1

Reversal Strategy Decision

If hemodynamically stable without compartment syndrome:

• Supportive care alone is reasonable: local compression, limb elevation, ice application, and observation 1
• Monitor for hematoma expansion with serial physical examinations and hemoglobin checks 1
• No reversal agent needed if hemostasis achieved 1

If hemodynamically unstable, expanding hematoma, or compartment syndrome develops:

• Administer andexanet alfa as the specific reversal agent for apixaban 1
• Dosing depends on apixaban timing and dose 1:
  • Low-dose andexanet (400 mg IV bolus followed by 4 mg/min infusion for 120 minutes): if last apixaban dose ≤5 mg was taken <8 hours prior or timing unknown
  • High-dose andexanet (800 mg IV bolus followed by 8 mg/min infusion for 120 minutes): if last apixaban dose >5 mg was taken <8 hours prior or timing unknown
• If andexanet alfa unavailable: administer four-factor prothrombin complex concentrate (4F-PCC) at 25-50 units/kg or activated PCC (aPCC) 1, 2

Consider Activated Charcoal

• Administer activated charcoal if apixaban was ingested within 2-4 hours to reduce absorption 1

Surgical Consultation

Obtain urgent orthopedic or vascular surgery consultation if:

• Compartment pressures exceed 30 mmHg or within 30 mmHg of diastolic blood pressure 1
• Progressive neurological deficits develop (foot drop, sensory loss) 1
• Hematoma continues expanding despite reversal 1

Fasciotomy may be required for compartment syndrome despite the bleeding risk 1

Monitoring Parameters

• Serial hemoglobin/hematocrit every 4-6 hours initially 1
• Compartment checks every 2-4 hours: pain, paresthesias, pallor, pulselessness, paralysis 1
• Calf circumference measurements to track hematoma expansion 1
• Renal function to estimate apixaban clearance time 1

Restarting Anticoagulation

Timing depends on the indication for apixaban:

• For atrial fibrillation: restart when bleeding risk is controlled, typically 24-48 hours after hemostasis achieved and hematoma stabilized 1
• For venous thromboembolism (VTE): the decision is more complex 1
  • If provoked VTE by transient risk factor and >3 months of treatment completed: may not need to restart 1
  • If unprovoked VTE or cancer-associated VTE requiring indefinite therapy: restart as soon as bleeding risk permits, typically 48-72 hours after stabilization 1
  • Consider reduced-intensity apixaban 2.5 mg twice daily if VTE occurred ≥6 months ago 1

Reassess the risk-benefit ratio of continuing anticoagulation given this major bleeding event 1

Common Pitfalls to Avoid

• Do not delay reversal in hemodynamically unstable patients while waiting for laboratory confirmation of apixaban levels 1
• Do not miss compartment syndrome: a 6.3 cm hematoma in the calf is high-risk, and delayed fasciotomy leads to permanent disability 1
• Do not restart anticoagulation prematurely: ensure complete hemostasis and hematoma stability before resuming apixaban 1
• Do not use vitamin K: it has no effect on direct oral anticoagulants like apixaban 1
• Do not ignore the underlying indication: if anticoagulation is for high-risk condition (mechanical valve, recent VTE), consult hematology for bridging strategies 1