Management of Profuse Epistaxis with INR 7
For a patient with profuse epistaxis and INR 7, administer prothrombin complex concentrate (PCC) plus vitamin K immediately while simultaneously applying aggressive local control measures. 1
Immediate Reversal Strategy
PCC is the preferred reversal agent because it provides rapid correction of INR with faster onset of action and smaller infusion volume compared to FFP. 1
- Vitamin K must be given concurrently with PCC to maintain sustained reversal, as PCC's effect is immediate but temporary 1
- Vitamin K alone should never be used for life-threatening bleeding because it takes a minimum of 1-2 hours for measurable improvement in prothrombin time 2
- FFP is only an alternative if PCC is unavailable, but it is significantly inferior 1
Why FFP is Inadequate
FFP fails to adequately correct coagulopathy in warfarin-associated bleeding:
- FFP does not completely normalize INR - studies show post-transfusion INR remains elevated (range 1.6-3.8, mean 2.3), indicating ongoing anticoagulation 3
- Factor IX levels remain critically low after FFP (median 19 u/dL) versus adequate levels with concentrate (median 68.5 u/dL) 3
- FFP has variable content of vitamin K-dependent clotting factors and dilutional effects that limit efficacy 3
- In critically ill patients with coagulopathy, FFP transfusion fails to induce a more procoagulant state 4
Why Other Options Are Wrong
- Cryoprecipitate is not indicated - it contains fibrinogen, factor VIII, and von Willebrand factor, but lacks the vitamin K-dependent factors (II, VII, IX, X) needed to reverse warfarin 1
- ECA (external carotid artery) ligation is a surgical intervention reserved for intractable epistaxis after failure of medical management and nasal packing, not initial treatment 5
Concurrent Local Control Measures
While administering PCC and vitamin K, immediately initiate:
- Firm sustained compression to the lower third of the nose for 10-15 minutes without checking if bleeding has stopped 1, 6
- Topical vasoconstrictors (oxymetazoline or phenylephrine) after clearing clots, which stops 65-75% of epistaxis cases 1, 6, 5
- Nasal packing with resorbable materials if compression and vasoconstrictors fail - resorbable packing is specifically recommended for anticoagulated patients to avoid trauma during removal 1, 6
Severity Assessment
This patient meets criteria for severe bleeding based on:
- Profuse active bleeding with INR 7 (dangerously elevated) 1
- Severe bleeding is defined as posterior nosebleed, hemodynamic instability, or hemoglobin decrease ≥2 g/dL 1
Critical Pitfall to Avoid
Do not give additional doses of anticoagulant medication while bleeding is active 1. However, do not permanently discontinue anticoagulation without consulting the primary team managing anticoagulation, as the thrombotic risk may outweigh bleeding risk once hemostasis is achieved 1, 7.
Dosing Specifics
- PCC: 4-factor PCC is preferred for warfarin reversal 1
- Vitamin K: 2.5-10 mg initially, up to 25 mg may be required for severe cases 2
- If INR has not shortened satisfactorily in 6-8 hours after parenteral administration, repeat the dose 2