What further management is recommended for a patient with persistent intermittent epistaxis (nosebleed) despite applying pressure and cold compresses, and currently holding aspirin and Eliquis (apixaban)?

From the Guidelines

The patient should seek immediate medical attention at an emergency department or ENT specialist for further evaluation and management of persistent intermittent epistaxis despite holding aspirin and Eliquis. The most recent and highest quality study 1 recommends topical treatments, including application of vasoconstricting agents such as oxymetazoline, phenylephrine, epinephrine, or cocaine and/or use of nasal cautery for patients with an identified anterior nasal bleeding site. Some key points to consider in the management of this patient include:

• The use of topical vasoconstrictors like oxymetazoline nasal spray to help reduce blood flow temporarily 1
• The potential need for nasal packing with materials such as Merocel or ribbon gauze to create direct pressure on the bleeding site 1
• The importance of maintaining head elevation, avoiding nose picking or blowing, and using saline nasal spray to keep mucosa moist 1
• The possibility of endoscopic evaluation to identify and treat the source of bleeding if it persists despite initial measures 1
• The consideration of surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization 1 It is crucial to prioritize the patient's safety and prevent potential complications such as anemia or hemodynamic instability due to continued blood loss. The patient should continue to hold anticoagulants until cleared by their physician and follow up with their clinician for further management and removal of any packing if necessary. In addition, the patient should be educated on preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care 1.

From the Research

Management of Persistent Intermittent Epistaxis

The patient's condition of persistent intermittent epistaxis despite applying pressure and cold compresses, and currently holding aspirin and Eliquis, requires further management.

• The current treatment options for epistaxis include first aid measures such as external pressure and ice packing, and applying topical agents like oxymetazoline, which can stop 65-75% of nosebleeds 2.
• Tranexamic acid can be used to promote hemostasis in 78% of patients, and has been shown to reduce the risk of re-bleeding compared to placebo 3.
• Endoscopic ligation of the sphenopalatine artery (ELSA) has been found to be an effective surgical option for managing persistent epistaxis, with a high success rate and shorter hospital stay compared to other surgical options 4.
• Topical application of tranexamic acid has been compared to anterior nasal packing in the management of epistaxis, and has been found to reduce bleeding time and number of rebleeds 5.
• Oxymetazoline has been used as an intranasal vasoconstrictor to effectively treat epistaxis, avoiding nasal packing in 65% of patients 6.

Treatment Options

Considering the patient's condition, the following treatment options can be considered:

• Application of topical tranexamic acid to promote hemostasis
• Use of oxymetazoline as an intranasal vasoconstrictor to reduce bleeding
• Endoscopic ligation of the sphenopalatine artery (ELSA) as a surgical option if other treatments fail
• Nasal packing with non-absorbable or absorbable materials as a last resort

Recommendations

Based on the available evidence, it is recommended to try topical tranexamic acid or oxymetazoline as a first-line treatment for the patient's epistaxis, and consider endoscopic ligation of the sphenopalatine artery (ELSA) if the bleeding persists. Nasal packing can be considered as a last resort.