What is the management approach for an acute nasal bleed in an elderly man on Eliquis (apixaban) anticoagulation therapy?

Management of Acute Nasal Bleeding in an Elderly Man on Eliquis

For an elderly man on Eliquis with acute epistaxis, continue the anticoagulation and manage with local measures—stopping Eliquis increases stroke risk 5-fold and is only warranted for life-threatening bleeding. 1, 2

Immediate Assessment: Determine Bleed Severity

First, classify whether this is a major or non-major bleed using these specific criteria 1:

Major bleeding requires ANY of:

• Hemodynamic instability (tachycardia, hypotension)
• Hemoglobin drop ≥2 g/dL
• Transfusion of ≥2 units RBCs
• Bleeding at a critical site (intracranial, spinal, intraocular, pericardial, retroperitoneal, intra-articular, or intramuscular with compartment syndrome) 1

Non-major bleeding = none of the above criteria are met, which applies to most epistaxis cases 1, 2

Critical Decision Point: Anticoagulation Management

For non-major epistaxis (most cases):

• Continue Eliquis and proceed with local bleeding control measures 1, 2
• Do NOT administer reversal agents (andexanet alfa)—they carry significant thrombotic risks without proven benefit for non-life-threatening bleeding 1, 2

For major epistaxis:

• Stop Eliquis temporarily 1
• Provide local therapy, supportive care, and volume resuscitation 1
• Consider reversal with andexanet alfa only if life-threatening 1

First-Line Local Treatment (All Patients)

Step 1: Proper Compression Technique

• Seat patient upright with head tilted slightly forward (not backward—this prevents aspiration) 1, 2, 3
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes 1, 2, 3, 4
• Do not check if bleeding has stopped before 15 minutes—premature release is the most common error 2, 3, 4
• Patient should breathe through mouth and spit out blood rather than swallow it 1, 2, 3

Common pitfall: Compression alone resolves the vast majority of anterior epistaxis, but providers often move to packing prematurely 1, 3

Step 2: Add Topical Vasoconstrictor

If bleeding continues after 15 minutes of proper compression 1, 2, 3:

• Apply oxymetazoline (Afrin) or phenylephrine spray—2 sprays into bleeding nostril 1, 3
• This stops bleeding in 65-75% of emergency department cases 1, 3, 5
• Resume firm compression for another 5-10 minutes 3

Step 3: Consider Topical Tranexamic Acid

If vasoconstrictor fails, topical tranexamic acid is highly effective 1, 6, 7:

• Reduces re-bleeding risk from 67% to 47% compared to placebo 6
• More effective than standard anterior nasal packing in patients on antiplatelet drugs 1
• Stops bleeding within 10 minutes in 76% of patients versus 34% with packing 7
• This is particularly valuable in anticoagulated patients 1, 6

Advanced Interventions When Compression Fails

Step 4: Identify and Cauterize Bleeding Site

After initial measures, if bleeding persists 1, 2, 3:

• Clean nasal cavity of clots by suction or gentle nose blowing 3
• Perform anterior rhinoscopy to identify the bleeding source 1, 3
• Apply topical anesthetic (lidocaine or tetracaine) 1
• Cauterize only the active bleeding site—avoid bilateral septal cautery as it increases perforation risk 1, 3
• Electrocautery is more effective than chemical cautery (14.5% vs 35.1% recurrence) 3, 5

Step 5: Nasal Packing (If Cautery Unavailable or Fails)

Critical for anticoagulated patients: Use only resorbable/absorbable materials to avoid trauma during removal 1, 2, 3, 4:

• Nasopore (nasal tampon) 2, 3
• Surgicel (hemostatic gauze) 2, 5
• Floseal (thrombin matrix) 3, 5
• Gelatin sponge (Spongostan) 5

Avoid non-resorbable packing (Merocel, BIPP gauze, petroleum jelly gauze) in patients on Eliquis 2, 3, 4

Prevention of Recurrence

Once bleeding is controlled 1, 2, 3, 4:

• Apply petroleum jelly or nasal saline gel to nasal mucosa twice daily 1, 2, 3
• Regular saline nasal sprays to maintain moisture 3, 4
• Humidifier use, especially in dry environments 4
• Avoid nasal manipulation, picking, or vigorous nose-blowing for 7-10 days 2, 3

When to Escalate Care

Refer to ENT or emergency department for 2, 3, 4:

• Bleeding persisting despite 30 minutes of proper compression with vasoconstrictors 2
• Hemodynamic instability 1, 2
• Large volume blood loss 2
• Signs of airway compromise 4
• Recurrent bleeding despite appropriate treatment 3, 4

For refractory cases, endoscopic sphenopalatine artery ligation has 97% success rate versus 62% for conventional packing 3, 5, and endovascular embolization achieves 80% success with <10% recurrence 3, 5.

Restarting Anticoagulation After Major Bleed

If Eliquis was temporarily stopped for major bleeding 1:

• Restart once adequate hemostasis is established (typically 24-48 hours) 1
• Delay restart if: bleeding at critical site, high rebleeding risk, source not identified, or surgery planned 1
• Balance thrombotic risk (stroke, PE) against bleeding risk—most patients should resume anticoagulation 1, 2

Key principle: The thrombotic risk of stopping Eliquis far exceeds the bleeding risk in most epistaxis cases, making continuation with local measures the safest approach 1, 2.