From the Guidelines
The patient's heparin drip should be temporarily discontinued, and first-line treatments such as nasal compression, vasoconstrictors, and nasal packing should be applied to control the bleeding. Management of a patient with persistent epistaxis while on a heparin drip for PE requires balancing bleeding control with anticoagulation needs. According to the clinical practice guideline on nosebleed (epistaxis) published in 2020 1, good local control efforts are important because reversal strategies have risks. The use of plasma, cryoprecipitate, and platelet transfusions expose patients to blood products and their associated risks.
Some key steps to consider in managing the patient's epistaxis include:
- Temporarily discontinuing the heparin infusion
- Applying direct pressure to the bleeding site by pinching the anterior nasal septum for 15-20 minutes
- Inserting nasal packing soaked in topical vasoconstrictors like oxymetazoline or phenylephrine
- Considering chemical cauterization with silver nitrate for visible bleeding vessels
- Consulting ENT for possible posterior packing or endoscopic intervention if bleeding persists
Once bleeding is controlled, the patient's anticoagulation therapy can be reassessed, potentially at a reduced dose or switching to an alternative like low molecular weight heparin, as recommended by the treating physician 1. It is crucial to monitor the patient's hemoglobin levels and vital signs for hemodynamic stability, as the risk of recurrent PE must be balanced against ongoing bleeding. In severe cases, consider IVC filter placement as a temporary measure if anticoagulation must be withheld for a prolonged period.
From the FDA Drug Label
OVERDOSAGE Symptoms Bleeding is the chief sign of heparin overdosage. Nosebleeds, blood in urine or tarry stools may be noted as the first sign of bleeding. Treatment Neutralization of Heparin Effect—When clinical circumstances (bleeding) require reversal of heparinization, protamine sulfate (1% solution) by slow infusion will neutralize heparin sodium.
The management for a patient with a persistent nose bleed (epistaxis) on a heparin drip for pulmonary embolism (PE) is to neutralize the heparin effect using protamine sulfate. The dose of protamine sulfate should be calculated based on the amount of heparin administered, with 1 mg of protamine sulfate neutralizing approximately 100 USP heparin units. The protamine sulfate should be administered slowly, with no more than 50 mg given in any 10 minute period 2.
From the Research
Management of Epistaxis in a Patient on Heparin Drip
The patient has a persistent nose bleed (epistaxis) while on a heparin drip for pulmonary embolism (PE). The management of epistaxis in this scenario involves:
- Identifying the source of the bleeding: anterior or posterior epistaxis 3
- Risk-stratifying the patient based on hemodynamic instability, source of bleeding, and degree of blood loss 4
- Discontinuing the heparin drip if the bleeding is severe or life-threatening
- Considering the use of protamine sulfate to reverse the anticoagulant effect of heparin 4, 5
Reversal of Anticoagulation
Reversal of anticoagulation is crucial in managing bleeding in patients on anticoagulants. The following options are available:
- Protamine sulfate for reversal of unfractionated heparin and low-molecular-weight heparin (LMWH) 4, 5
- Fresh frozen plasma or prothrombin complex concentrate (PCC) for reversal of warfarin 4
- Idarucizumab for reversal of dabigatran 4
- Andexanet alfa for reversal of oral factor Xa inhibitors 4
Specific Considerations for Heparin-Induced Bleeding
For patients on heparin, the following considerations apply: