Management of Lip Bleeding in a 68-Year-Old Woman in Primary Care
Apply direct manual compression with gauze for 3-5 minutes, and if the patient is on anticoagulants or antiplatelet agents, soak the gauze in tranexamic acid (10 mL of 5% solution) while continuing these medications unless the bleeding meets major bleeding criteria. 1
Immediate Assessment and Classification
First, determine if this is a non-major bleed (most likely) or a major bleed by checking for any of the following 2:
- Hemodynamic instability
- Hemoglobin decrease ≥2 g/dL from baseline
- Need for ≥2 units of RBC transfusion
- Active bleeding that cannot be controlled with simple local pressure after 15-20 minutes 1
Lip bleeding in primary care almost always qualifies as non-major bleeding unless the patient shows signs of hemodynamic compromise or meets the above criteria. 2
Management for Non-Major Lip Bleeding (Most Common Scenario)
If Patient is on Anticoagulants or Antiplatelet Agents:
Continue all anticoagulants and antiplatelet medications - do not stop them for non-major bleeding. 2, 1
Apply local hemostatic measures: 1
- Use gauze soaked in tranexamic acid (10 mL of 5% solution) applied directly to the bleeding site
- Maintain gentle manual compression for 3-5 minutes 1
- Clean the wound with sterile saline if needed 3
If Patient is NOT on Anticoagulants:
Apply direct manual compression with clean gauze for 3-5 minutes. 2
Consider topical vasoconstrictors such as oxymetazoline (Afrin) applied on gauze if simple compression fails. 2
Additional Assessment Steps
Check medication history to identify if the patient is taking: 2
- Warfarin or other vitamin K antagonists
- DOACs (apixaban, rivaroxaban, dabigatran, edoxaban)
- Antiplatelet agents (aspirin, clopidogrel, prasugrel, ticagrelor)
Assess for underlying bleeding disorders, particularly in women with a history of easy bruising, epistaxis, bleeding from minor wounds, or heavy menstrual bleeding, as these may indicate von Willebrand disease or platelet disorders. 4, 5
Evaluate for comorbidities that could contribute to bleeding: 2
- Thrombocytopenia
- Uremia
- Liver disease
When to Escalate Care
Refer to emergency department or specialist if: 2
- Bleeding persists despite 15-20 minutes of direct compression 1
- Patient develops hemodynamic instability
- Hemoglobin drops ≥2 g/dL
- Patient requires transfusion
Consider ENT or oral surgery consultation for cauterization or suturing if local measures fail. 2, 3
Management for Major Lip Bleeding (Rare)
If the bleeding meets major bleeding criteria: 2
Stop all anticoagulants and antiplatelet agents immediately. 2
Initiate aggressive measures: 2
- Volume resuscitation with IV crystalloids if hemodynamically unstable
- Continue local compression with tranexamic acid-soaked gauze
- Consider surgical/procedural management
Administer reversal agents if on anticoagulants: 2
- For warfarin: Give 5-10 mg IV vitamin K and consider prothrombin complex concentrate (PCC) if life-threatening
- For DOACs: Use andexanet alfa for apixaban/rivaroxaban or idarucizumab for dabigatran
Critical Pitfalls to Avoid
Do not administer reversal agents (PCC, vitamin K, idarucizumab, andexanet alfa) for non-major bleeding - these are reserved for major or life-threatening bleeds only. 2, 1
Do not stop anticoagulation for simple lip bleeding in patients with appropriate indications (atrial fibrillation, VTE, mechanical valves), as this exposes them to thrombotic risk. 2, 1
Do not confuse antiplatelet reversal with anticoagulant reversal - platelet transfusion may be needed for antiplatelet agents, not PCC or vitamin K. 2, 3
Follow-Up Considerations
Monitor for recurrent bleeding after initial hemostasis is achieved. 1, 3
Consider bleeding disorder workup if the patient has recurrent unexplained bleeding episodes, including complete blood count, PT/INR, aPTT, and possibly referral to hematology. 5, 6
Reassess anticoagulation/antiplatelet regimen with the prescribing physician if bleeding recurs, but do not unilaterally discontinue these medications. 2