Posterior epistaxis on a direct oral anticoagulant
A 72-year-old man with atrial fibrillation on apixaban 5 mg twice daily, hypertension, and moderate chronic kidney disease (eGFR 42 mL/min) is admitted with severe posterior epistaxis. He has had three episodes in 24 hours; anterior packing and chemical cautery by the emergency physician failed. His blood pressure is 178/96 mmHg, heart rate 96, and he is anxious. Hemoglobin is 10.8 g/dL (baseline 13.5), platelets 180, INR 1.1. He has no known bleeding disorder. The ENT resident suggests posterior nasal packing with a Foley catheter and admission for observation, but the patient asks whether he can go home because he has a wedding to attend tomorrow. His CHA2DS2-VASc score is 5. He lives alone with no escort and is reluctant to stop apixaban because his brother had a stroke.
1. What is your immediate management, including anticoagulation strategy?
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This is a severe posterior epistaxis with haemodynamic compromise (Hb drop from 13.5 to 10.8 g/dL) and uncontrolled hypertension. He requires admission to a monitored bed, intravenous access, and blood pressure control (target systolic <140 mmHg if tolerated). Posterior packing with a Foley catheter or double-balloon device is appropriate, but he needs to be monitored for nasopulmonary reflex (bradycardia, hypoxia) and should receive antibiotics to prevent toxic shock syndrome. Anticoagulation: apixaban should be held because of active bleeding and dropping haemoglobin. For life-threatening bleeding, reversal with andexanet alfa or prothrombin complex concentrate can be considered, but the risk of stroke (CHA2DS2-VASc 5) is high, so this decision should be made with cardiology and haematology. I would not reverse unless bleeding is uncontrollable. Once haemostasis is achieved (usually 24–48 hours), restart apixaban after multidisciplinary discussion. He cannot go home for the wedding; he needs admission. I would also correct hypertension and consider CT angiography if packing fails.
2. If bleeding persists after posterior packing, what are the next steps and how do you choose between sphenopalatine artery ligation and embolization?
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Persistent posterior epistaxis after adequate packing usually arises from the sphenopalatine artery. The next step is endoscopic sphenopalatine artery ligation, which can be performed under general anaesthesia with low morbidity and a high success rate. It avoids the risks of angiography, including stroke, blindness, and groin complications. Embolization is an alternative if sphenopalatine artery ligation fails, if the bleeding source is not accessible endoscopically, or if the patient is a poor surgical candidate. In this patient, who is anticoagulated and has chronic kidney disease, I would favour sphenopalatine artery ligation because it is definitive and does not require contrast. However, if he is unstable or has an aberrant vascular supply, embolization by interventional radiology may be preferred. I would also consider repeat packing with a balloon and check for coagulopathy. The choice depends on local expertise, the patient's fitness, and the availability of interventional radiology. I would involve a multidisciplinary team and discuss the risks of stroke with embolization.