How to manage nasal bleeding in an 80-year-old male on Eliquis (apixaban) with a history of stroke who presents to the emergency department (ED)?

Management of Nasal Bleeding in an 80-Year-Old Male on Eliquis with History of Stroke

For an 80-year-old male on apixaban (Eliquis) with history of stroke presenting with nasal bleeding to the ED, first-line treatment should include firm sustained compression to the lower third of the nose for 10-15 minutes, followed by topical vasoconstrictors, while maintaining anticoagulation unless bleeding is life-threatening.

Initial Assessment and Management

1. Apply firm sustained compression:

   • Apply firm pressure to the lower third of the nose (anterior nares) for 10-15 minutes 1
   • This simple technique has high success rates when performed correctly
   • Patient should be sitting upright, leaning slightly forward to prevent blood from flowing down the throat

2. Identify bleeding site:

   • After compression, perform anterior rhinoscopy to identify the source of bleeding 2
   • Remove any blood clots gently to improve visualization
   • If anterior rhinoscopy is insufficient, nasal endoscopy should be performed to identify posterior bleeding sites

3. Apply topical vasoconstrictors:

   • Use oxymetazoline or phenylephrine-soaked cotton pledgets to the bleeding site 1
   • Success rate of 65-75% for controlling epistaxis
   • Apply for 5-10 minutes

Anticoagulation Management

Important: In the absence of life-threatening bleeding, do NOT reverse or discontinue anticoagulation 2, 1

• Continue apixaban therapy as the risk of thrombotic events (especially with history of stroke) outweighs the risk of continued nasal bleeding
• Premature discontinuation of apixaban increases the risk of thrombotic events 3
• First-line treatments should be initiated prior to considering any changes to anticoagulation 2

Advanced Management Options

If bleeding persists despite initial measures:

1. Topical tranexamic acid:

   • Apply via cotton pledgets soaked with TXA solution to the bleeding site 1
   • Particularly effective in patients on antiplatelet or anticoagulant medications

2. Nasal cautery:

   • If a specific bleeding site is identified, chemical or electrical cautery can be performed under local anesthesia 2, 1
   • Restrict application only to the active bleeding site to prevent septal damage

3. Nasal packing:

   • For persistent bleeding not controlled by above measures 2
   • Use resorbable packing materials for patients on anticoagulants 2, 1
   • Educate patient about the type of packing, removal plan (if non-resorbable), and signs requiring reassessment

Special Considerations for This Patient

• Age and anticoagulation: At 80 years, this patient is at higher risk for both bleeding complications and stroke recurrence
• History of stroke: This significantly increases the importance of maintaining anticoagulation 4
  • Recent evidence shows patients with history of stroke and atrial fibrillation have a 7% absolute risk reduction in stroke or systemic embolism over 3.5 years with apixaban compared to aspirin 4
• Avoid nasal trauma: Educate patient to avoid digital trauma (nose picking), vigorous nose blowing, and to use nasal moisturization with saline gel/spray 1-3 times daily to prevent recurrence 1

When to Consider More Aggressive Intervention

Escalate care if:

• Bleeding cannot be controlled with the above measures
• Signs of hemodynamic instability develop
• Bilateral bleeding or bleeding from posterior sites
• Bleeding duration >30 minutes despite compression 2

Discharge Planning and Prevention

1. Nasal moisturization:

   • Recommend saline gel or spray 1-3 times daily 1
   • Consider home humidification in dry environments

2. Patient education:

   • Proper technique for nasal compression if bleeding recurs
   • Avoid digital trauma and vigorous nose blowing
   • Warning signs requiring return to ED (recurrent heavy bleeding, swallowing large amounts of blood)

3. Follow-up:

   • Document outcome within 30 days or ensure transition of care 2
   • Consider ENT referral if recurrent episodes occur

This approach prioritizes both bleeding control and stroke prevention in this high-risk patient, recognizing that maintaining anticoagulation is crucial for preventing potentially devastating thromboembolic events in a patient with prior stroke history.