How to manage epistaxis in a patient on anticoagulants (blood thinners)?

Management of Epistaxis in Anticoagulated Patients

Do not stop or reverse anticoagulation for epistaxis unless the bleeding is life-threatening or at a critical site—instead, prioritize aggressive local control measures first. 1, 2

Immediate First-Line Treatment

The cornerstone of management is firm, continuous compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped. 2, 3

• Position the patient sitting upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or stomach 4, 2
• Apply direct pressure by pinching the soft part of the nose firmly for the full duration 2, 3
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 3
• This approach alone resolves the majority of anterior epistaxis cases, even in anticoagulated patients 2, 3

If Bleeding Persists After 15 Minutes of Compression

• Apply a topical vasoconstrictor (oxymetazoline or phenylephrine spray—2 sprays in the bleeding nostril) 4, 2
• Continue compression for another 5-10 minutes after vasoconstrictor application 2
• This combination stops bleeding in 65-75% of cases that don't respond to compression alone 4, 3

Critical Anticoagulation Management Principles

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against withholding anticoagulation, reversing it, or administering blood products for non-life-threatening epistaxis. 2

For Non-Life-Threatening Bleeding:

• Continue the anticoagulant and focus on local control measures 1, 2
• Do not take additional doses of the anticoagulant while actively bleeding 2
• First-line local control measures should always be attempted before considering any anticoagulation reversal 2

For Life-Threatening or Critical Site Bleeding:

• Stop the anticoagulant immediately 1
• For warfarin: administer 5-10 mg IV vitamin K 1
• For DOACs (dabigatran, rivaroxaban, apixaban): consider specific reversal agents only if life-threatening 1
  • Idarucizumab for dabigatran 1
  • Andexanet alfa for apixaban or rivaroxaban 1
• For warfarin with life-threatening bleeding: administer 4-factor prothrombin complex concentrate 1, 2

Critical site bleeds include: posterior epistaxis causing airway compromise, hemodynamic instability, or bleeding requiring ≥2 units of packed red blood cells 1

Advanced Management if Basic Measures Fail

Nasal Packing:

• Use resorbable/absorbable packing materials in anticoagulated patients to avoid trauma during removal 3
• Posterior nasal packing with tranexamic acid-soaked gauze may be used for posterior epistaxis 3
• Consider a Foley catheter for posterior packing if needed 3

Adjunctive Hemostatic Agents:

• Antifibrinolytic agents (tranexamic acid) or desmopressin may support hemostasis without reversing anticoagulation 2
• These can be used while maintaining therapeutic anticoagulation 2

Surgical/Procedural Options:

• Nasal cauterization (chemical or electrocautery) if a bleeding point is identified 4, 3
• Endoscopic evaluation to localize the bleeding site (successful in 87-93% of cases) 3
• Surgical arterial ligation or endovascular embolization for refractory cases (success rate >90%, recurrence <10%) 1, 3

When to Seek Emergency Medical Attention

Patients on anticoagulants should seek professional medical care for epistaxis, especially if: 2

• Bleeding does not stop after 15 minutes of continuous pressure 4, 2
• Lightheadedness, dizziness, or weakness from blood loss occurs 2
• Signs of hemodynamic instability develop (tachycardia, hypotension, orthostatic changes) 1
• Bleeding duration exceeds 30 minutes over a 24-hour period 4

Prevention of Recurrence

Once bleeding has stopped: 4, 2

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 4, 2, 3
• Use saline nasal sprays regularly to keep nasal passages moist 4, 2
• Consider using a humidifier, especially in dry environments 2
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7-10 days 3

Restarting Anticoagulation After Bleeding Control

• For non-life-threatening epistaxis controlled with local measures: continue anticoagulation without interruption 1, 2
• For major bleeding requiring anticoagulation reversal: restart typically within 24-48 hours after confirmed hemostasis, balancing thrombotic versus bleeding risk 1, 3
• Delay restart if bleeding occurred at a critical site, high risk of rebleeding exists, or the source has not been identified 1

Common Pitfalls to Avoid

• Insufficient compression time (checking too early) leads to treatment failure 2, 3
• Tilting head backward causes blood to flow into the throat and does not help control bleeding 2
• Unnecessary anticoagulation reversal dramatically increases stroke risk and should only occur in life-threatening scenarios 2
• Using non-resorbable packing in anticoagulated patients increases trauma risk during removal 3
• Premature hospital discharge without adequate hemostasis confirmation in high-risk patients 1