What is the next management step for a 75-year-old male on Direct Oral Anticoagulant (DOAC) for atrial fibrillation (a fib) with recurrent epistaxis and stable vital signs, but ongoing bleeding from the right nostril?

Management of Ongoing Epistaxis in a 75-Year-Old Male on DOAC with Stable Vitals

The immediate next step is to apply firm sustained compression to the lower third of the nose for 5-15 minutes while the patient sits with head tilted slightly forward, followed by topical vasoconstrictor application if bleeding persists, and use resorbable nasal packing if these measures fail—all while continuing the DOAC without reversal since the patient is hemodynamically stable. 1, 2

Immediate Local Control Measures

First-Line Intervention: Direct Compression

• Apply firm, sustained compression to the soft lower third of the nose for 10-15 minutes continuously with the patient seated and head tilted slightly forward to prevent blood from flowing into the airway or stomach 1, 2, 3
• The patient should breathe through the mouth and spit out blood rather than swallowing it 2, 3
• This compression alone controls bleeding in the majority of cases 3

Second-Line: Topical Vasoconstrictors

• If compression for 15 minutes fails to control bleeding, clean the nasal cavity of clots and apply a topical vasoconstrictor (oxymetazoline or phenylephrine) 1, 2, 3
• Vasoconstrictor application stops bleeding in 65-75% of emergency department cases 3

Third-Line: Nasal Packing

• If bleeding continues after compression and vasoconstrictor application, proceed to nasal packing using resorbable packing materials 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends resorbable packing for patients on anticoagulants or antiplatelet medications 1, 2, 3
• This avoids the need for painful removal procedures and reduces rebleeding risk in anticoagulated patients 1

Critical Decision: Continue vs. Withhold DOAC

Do NOT Reverse Anticoagulation

• In the absence of life-threatening bleeding, continue the DOAC and initiate first-line local treatments rather than reversing or withdrawing anticoagulation 1, 2
• This patient has stable vital signs, which indicates non-major bleeding despite recurrence 1
• Major bleeding is defined by the American College of Cardiology as bleeding at a critical site, hemodynamic instability, OR hemoglobin decrease ≥2 g/dL or transfusion of ≥2 units RBCs 1
• Since this patient has stable vitals and ongoing oozing (not life-threatening hemorrhage), local measures take priority over anticoagulation reversal 1, 2

When to Consider DOAC Reversal

• Reversal agents (andexanet alfa for factor Xa inhibitors, idarucizumab for dabigatran) should only be considered if the patient develops hemodynamic instability or life-threatening bleeding 1, 4
• The International Society on Thrombosis and Hemostasis recommends considering reversal only for serious bleeding with DOAC levels >50 ng/mL 1

Diagnostic Evaluation

Anterior Rhinoscopy

• Perform anterior rhinoscopy to identify the bleeding source after removing any blood clots (by suction or gentle nose blowing) 1
• This allows visualization of the anterior nasal cavity and may reveal the specific bleeding site for targeted cautery 1

Nasal Endoscopy for Recurrent Cases

• Since this patient has had epistaxis x2 (recurrent), nasal endoscopy should be performed or the patient referred to otolaryngology to identify the bleeding site and guide further management 1, 2
• Endoscopy is particularly important for recurrent bleeding despite prior treatment, as it can identify posterior bleeding sources not visible on anterior rhinoscopy 1

Definitive Treatment Options

Nasal Cautery

• If a specific bleeding site is identified on examination, apply topical anesthesia and restrict cautery application only to the active or suspected bleeding site 1
• This provides definitive control for anterior bleeding sources 1

Surgical Intervention for Refractory Cases

• Evaluate candidacy for surgical arterial ligation or endovascular embolization if bleeding persists despite packing or cauterization 1, 2, 3
• This is reserved for patients with persistent or recurrent bleeding not controlled by conservative measures 1

Supportive Care and Monitoring

Volume Resuscitation (If Needed)

• Although this patient has stable vitals, monitor for signs of hemodynamic compromise 1
• If instability develops, initiate aggressive volume resuscitation with isotonic crystalloids (0.9% NaCl or Ringer's lactate) 1

Blood Product Transfusion Thresholds

• Transfuse RBCs to maintain hemoglobin ≥7 g/dL in patients with symptomatic anemia or active bleeding 1
• For patients with underlying coronary artery disease, maintain hemoglobin ≥8 g/dL 1

Prevention of Recurrence

Nasal Moisturization

• Apply moisturizing or lubricating agents (petroleum jelly) to the nasal mucosa to prevent recurrence 1, 2, 3
• Recommend regular use of saline nasal sprays to keep nasal mucosa moist 2, 3

Patient Education

• Educate the patient about preventive measures, home treatment techniques (proper compression technique), and indications to seek additional medical care 1, 2
• If nasal packing is placed, educate about the type of packing, timing and plan for removal (if non-resorbable), postprocedure care, and warning signs requiring reassessment 1

Follow-Up

• Document the outcome of intervention within 30 days 1, 2
• Arrange otolaryngology follow-up for this patient with recurrent epistaxis to evaluate for underlying pathology and consider definitive treatment options 1, 2

Common Pitfalls to Avoid

• Do not routinely discontinue or reverse DOACs for non-life-threatening epistaxis—this increases thromboembolic risk without proven benefit for minor bleeding 1, 2
• Do not use non-resorbable packing in anticoagulated patients when resorbable options are available, as removal can precipitate rebleeding 1, 2
• Do not apply bilateral nasal cautery or excessive cautery beyond the bleeding site, as this increases risk of septal perforation 1
• Do not administer reversal agents (andexanet alfa, idarucizumab) for stable, non-life-threatening bleeding, as they carry thromboembolic risks (18% rate in ANNEXA-4 study) 4