What is the management of acute nasal bleeding in a male patient on Eliquis (apixaban)?

Management of Acute Nasal Bleeding in a Man on Eliquis

Continue Eliquis and manage the epistaxis with local measures—do not discontinue, withhold, or reverse anticoagulation for non-life-threatening nosebleeds, as the thrombotic risk far exceeds the bleeding risk. 1

Immediate Assessment and Triage

Determine bleeding severity to guide management intensity:

• Non-major bleeding (most epistaxis cases): No hemodynamic instability, hemoglobin drop <2 g/dL, no transfusion needed 2
• Major bleeding requires: Hemodynamic instability OR hemoglobin decrease ≥2 g/dL OR transfusion of ≥2 units RBCs 2

Check vital signs including orthostatic changes to assess for significant blood loss 1. Look for active nasal drainage, blood in the oropharynx, or signs of ongoing bleeding 1.

First-Line Treatment (Do NOT Stop Eliquis)

Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 2, 3. The patient should:

• Sit upright with head slightly forward (not tilted back) 3
• Breathe through the mouth and spit out blood rather than swallow it 3
• Avoid checking the nose during compression, as this disrupts clot formation 3

If bleeding continues after 15 minutes of proper compression:

• Clean the nasal cavity of clots by gentle nose blowing or suction 3
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril 3
• Resume firm compression for another 10-15 minutes 3

This approach stops bleeding in 65-75% of emergency department cases 3.

Advanced Interventions When Compression Fails

Perform anterior rhinoscopy after clot removal to identify the bleeding source 2, 3.

If a bleeding site is identified:

• Apply topical anesthetic to the bleeding site 2
• Perform nasal cautery (chemical or electrocautery) restricted only to the active bleeding site 2
• Avoid bilateral simultaneous septal cautery due to perforation risk 3

If bleeding persists or no site is identified:

• Use resorbable/absorbable packing materials ONLY (Nasopore, Surgicel, Floseal) in patients on Eliquis 2, 3
• This is a critical distinction—the American Academy of Otolaryngology-Head and Neck Surgery specifically recommends resorbable packing for anticoagulated patients to avoid trauma during removal 2, 3
• Educate the patient about post-packing care, including timing of follow-up and signs requiring urgent reassessment 2

Critical Anticoagulation Management

DO NOT discontinue Eliquis for controlled epistaxis:

• The stroke risk in atrial fibrillation patients increases 5-fold when anticoagulation is stopped 1
• First-line treatments should be initiated prior to any consideration of anticoagulation withdrawal 2
• The FDA label confirms that premature discontinuation increases thrombotic event risk 4

DO NOT administer reversal agents (andexanet alfa) or prothrombin complex concentrates for non-life-threatening epistaxis:

• These carry significant thrombotic risks without proven benefit in this setting 1
• Reversal is reserved only for life-threatening bleeding with hemodynamic compromise 2

Only consider stopping Eliquis if:

• Bleeding is at a critical site (intracranial, intraspinal, intraocular, pericardial) 2
• Life-threatening bleeding with hemodynamic instability is present 2
• Standard local measures have completely failed 2

Prevention of Recurrence

Prescribe nasal moisturizers:

• Apply topical nasal saline gel or petroleum jelly twice daily to prevent mucosal drying and crusting 1, 3
• Use saline sprays regularly to maintain nasal moisture 3
• Use humidifiers, especially in dry environments 3

Instruct the patient to avoid:

• Nasal manipulation, picking, or vigorous nose-blowing for 7-10 days 3
• Nasal decongestant sprays during the healing period 3

When to Escalate Care

Refer for specialist evaluation if:

• Recurrent epistaxis occurs within 10 days despite proper management 1
• Bleeding persists despite 15-30 minutes of proper compression with vasoconstrictors 3
• Nasal endoscopy is needed to localize posterior bleeding sources 2, 3

Consider surgical intervention (endoscopic sphenopalatine artery ligation or endovascular embolization) for persistent or recurrent bleeding not controlled by packing or cauterization 2. These have success rates of 97% and 80% respectively, compared to 62% for conventional packing 3.

Red Flags Requiring Emergency Department Evaluation

Instruct the patient to seek immediate care for:

• Hemodynamic instability (lightheadedness, syncope, tachycardia) 1
• Large volume blood loss that soaks through multiple towels 1
• Bleeding that persists despite 30 minutes of proper compression 1
• Signs of airway compromise 2

Common Pitfalls to Avoid

Never discontinue Eliquis reflexively for simple epistaxis—this is the most dangerous error, as it dramatically increases stroke risk without improving outcomes 1.

Never use non-resorbable packing in anticoagulated patients, as removal causes rebleeding and trauma 2, 3.

Never apply ice packs as first aid—current evidence shows no benefit for acute epistaxis 3.

Never perform bilateral septal cautery simultaneously due to perforation risk 3.