Posterior Epistaxis on Apixaban with a Falling Haemoglobin
A 71-year-old man presents at 02:00 with 5 hours of right-sided epistaxis. He takes apixaban 5 mg twice daily for atrial fibrillation and amlodipine 10 mg daily. Blood pressure is 178/96 mmHg, pulse 96 irregular, SpO2 97%. He has had two anterior nasal packs inserted at a walk-in clinic, both soaked through, and is spitting blood into a bowl. Haemoglobin is 10.2 g/dL, having been 13.4 g/dL four months earlier; platelets 210 ×10⁹/L, creatinine 110 µmol/L, eGFR 52. He is alert but anxious, and his respiratory rate is 22/min. The on-call ENT registrar is 45 minutes away; there is no endoscope or diathermy available overnight, and no interventional radiology on site.
1. Outline your immediate management in the first hour, including why bilateral posterior packing is avoided.
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First hour
- Airway, breathing and circulation: sit upright, apply oxygen if needed, attach monitoring, obtain two large-bore cannulae and send group and save, full blood count and coagulation screen (including anti-Xa level if available, though not required to act).
- Insert a unilateral posterior pack: a catheter balloon (Foley) passed through the nose and inflated in the nasopharynx with light anterior traction, or a dedicated double-balloon device. A posterior pack alone often requires an anterior pack as well for complete control.
- Control blood pressure: treat pain and anxiety, then use titratable intravenous agents (e.g. labetalol or hydralazine) aiming for a systolic around 140–150 mmHg in the acute phase, avoiding precipitous drops.
- Resuscitate with crystalloid cautiously; transfuse if haemoglobin falls below 7–8 g/dL or if there is ongoing bleeding with cardiovascular compromise.
Why not bilateral posterior packs Bilateral posterior packing obstructs the nasopharyngeal airway, causes hypoxia, hypercapnia and sleep apnoea, and can precipitate arrhythmias; it also blocks sinus drainage and raises the risk of toxic shock and aspiration. It is reserved for catastrophic haemorrhage where no other option exists, with airway protection and intensive care.
2. The bleeding is controlled with a posterior pack. Would you reverse apixaban now, and how do you decide on definitive treatment?
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Reversal decision
- Not routinely. The bleeding is controlled and the patient is haemodynamically stable; reversing anticoagulation exposes him to stroke risk from atrial fibrillation (CHA₂DS₂-VASc is high) without clear benefit.
- If bleeding is life-threatening or continues despite packing, consider andexanet alfa where available, or prothrombin complex concentrate as a pragmatic alternative; discuss with haematology and cardiology.
- Do not give vitamin K or fresh frozen plasma for a direct factor Xa inhibitor; they do not reverse it effectively.
- The last dose timing matters: apixaban has a half-life of about 12 hours and renal impairment prolongs it, so time any procedure at the trough (about 12 hours after the last dose).
Definitive treatment
- Admit for monitoring, oxygen, and pack care; keep the pack no longer than 48–72 hours and use antibiotics covering staphylococci and anaerobes if a posterior pack remains.
- Arrange endoscopy within 24–48 hours to identify the bleeding point; if it is posterior and accessible, endoscopic sphenopalatine artery ligation or cautery is preferred to further packing.
- If endoscopy fails or the patient is unfit, request interventional radiology for embolisation at the tertiary centre.
- Address contributors: hypertension control, avoid NSAIDs, review apixaban dose against renal function and age, and treat any nasal cause such as septal spur or telangiectasia.
3. On day 2 the patient develops a temperature of 38.6°C and purulent nasal discharge with the pack still in situ. How do you interpret and manage this?
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Interpretation
- A low-grade fever on day 2 with a posterior pack is most often a pack-related sinusitis or a systemic inflammatory response, but toxic shock syndrome must be excluded: look for rash, hypotension, diarrhoea, confusion and rising inflammatory markers.
- Aspiration, and in an elderly patient hospital-acquired pneumonia, should also be considered; examine the chest and obtain a chest radiograph and blood cultures if unwell.
- The pack acting as a foreign body obstructs sinus drainage and promotes staphylococcal growth; this is expected and is not an automatic reason for removal if bleeding is controlled.
Management
- Examine for toxic shock features; if present, remove the pack immediately, resuscitate and start broad-spectrum cover including clindamycin or linezolid (antitoxin effect) and urgent ENT/intensive care input.
- If there are no red flags, start oral antibiotics with antistaphylococcal cover (e.g. co-amoxiclav plus nasal mupirocin), take cultures, and plan pack removal within 24–48 hours with the airway team present.
- Reassess the need for the pack: if bleeding has settled, remove it under direct vision with suction and equipment for re-packing, and observe for 24 hours.
- Document a plan for anticoagulation restart, usually 24–48 hours after bleeding has stopped, with cardiology agreement.