Should a 73-year-old woman with recurrent epistaxis, stable hemoglobin, mildly prolonged prothrombin time and INR 1.3 due to cirrhosis, and comorbid hypertension, insulin-dependent diabetes mellitus, gastroesophageal reflux disease, asthma, chronic anemia, and diastolic heart failure receive any immediate systemic treatment or just local measures and ENT evaluation?

Management of Recurrent Epistaxis in a 73-Year-Old with Cirrhosis and Stable Hemodynamics

This patient requires local preventive measures and ENT follow-up, but no immediate systemic treatment for coagulopathy or transfusion, because her hemoglobin is stable, bleeding has stopped, and the mildly elevated INR 1.3 reflects cirrhotic synthetic dysfunction rather than active hemorrhagic risk requiring reversal. 1

Immediate Assessment Priorities

Hemodynamic Stability Confirmation

• Document vital signs including orthostatic changes to exclude occult blood loss, as tachycardia, hypotension, or orthostatic changes indicate significant hemorrhage requiring hospital-level escalation. 1
• Her stable H/H 11.6/37 and absence of active bleeding on arrival confirm she does not meet criteria for urgent intervention. 1

Risk Factor Documentation

• Record her complete medication list including any anticoagulants, antiplatelet agents (aspirin, clopidogrel), NSAIDs, and intranasal medications, as these markedly increase epistaxis severity and recurrence. 1, 2
• Document her diastolic CHF and hypertension, which are independent risk factors for recurrent epistaxis; CHF is particularly underappreciated but significantly increases recurrence risk. 2
• Note her cirrhosis and baseline anemia, as chronic liver disease patients have complex coagulation defects that prolong PT/INR but do not necessarily reflect true bleeding risk. 3

Why No Immediate Coagulopathy Treatment Is Needed

The INR 1.3 Does Not Require Reversal

• Do not administer FFP, vitamin K, or prothrombin complex concentrate for an INR of 1.3 in a hemodynamically stable patient with controlled bleeding, because the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against reversing anticoagulation unless bleeding is life-threatening or uncontrolled by local measures. 1
• Thrombin generation in cirrhotic patients remains within normal limits despite PT/INR prolongation, and in vitro studies show that adding normal plasma does not appreciably change thrombin generation even though PT shortens. 3
• Her PT 144.0 seconds (assuming this is a typo for 14.4 seconds, corresponding to INR 1.3) reflects hepatic synthetic dysfunction, not consumptive coagulopathy or warfarin effect. 3

No Transfusion Indicated

• Her hemoglobin 11.6 g/dL is stable for her baseline anemia and does not meet transfusion thresholds in the absence of active bleeding or hemodynamic compromise. 1
• Initiate first-line local hemostatic measures before considering blood products unless bleeding is life-threatening. 1

Local Preventive Measures to Prescribe Now

Nasal Mucosal Moisturization

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to prevent recurrence by maintaining mucosal moisture. 1
• Prescribe saline nasal sprays for frequent use throughout the day to keep the nasal mucosa moist, especially important in elderly patients prone to dryness-related bleeding. 1
• Recommend a humidifier in her living environment, as dry heat and low humidity create fragile, hyperemic nasal mucosa that bleeds easily. 1

Blood Pressure Optimization (Outpatient)

• Do NOT aggressively lower blood pressure acutely during or immediately after epistaxis, as excessive reduction can cause renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension. 1, 4
• Arrange outpatient optimization of her hypertension control over days to weeks, as hypertension is independently associated with more severe epistaxis requiring emergency intervention. 4, 2

ENT Referral Indications and Timing

Arrange Outpatient ENT Evaluation

• Refer to otolaryngology for nasal endoscopy because recurrent epistaxis in a 73-year-old warrants examination to exclude unrecognized pathology (masses, vascular malformations, hereditary hemorrhagic telangiectasia). 1, 5
• Nasal endoscopy localizes the bleeding site in 87–93% of cases and is specifically recommended for recurrent bleeding despite prior treatment. 1
• ENT can perform targeted cautery if a focal bleeding point is identified, which has lower recurrence rates (14.5% for electrocautery) compared to no definitive treatment. 1

Urgent ENT Consultation Is NOT Required Unless:

• Bleeding recurs and persists despite 15 minutes of proper continuous compression. 1
• She develops hemodynamic instability (tachycardia, hypotension, syncope). 1
• Fever >101°F, vision changes, or facial swelling develop (suggesting complications of occult packing or infection). 1

Patient Education for Home Management

Immediate Self-Care Instructions

• If bleeding recurs, sit upright with head tilted slightly forward and apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking if bleeding has stopped. 1, 4
• Breathe through the mouth and spit out blood rather than swallow it to prevent nausea and allow assessment of bleeding volume. 1
• Avoid nose-picking, vigorous nose-blowing, and nasal manipulation for at least 7–10 days to allow healing. 1

Return Precautions

• Return to the ER immediately if bleeding persists after 15 minutes of continuous proper compression, if bleeding duration exceeds 30 minutes over a 24-hour period, or if signs of hemodynamic instability develop (dizziness, palpitations, chest pain). 1

Why CT Sinus Is Pending (Appropriate Workup)

• CT sinus with contrast is reasonable to exclude structural lesions, masses, or sinus pathology that could explain recurrent unilateral or bilateral epistaxis, especially in elderly patients. 5
• Unilateral epistaxis accompanied by nasal obstruction, facial pain, or visual changes raises concern for intranasal tumors, which CT can help identify. 5

Common Pitfalls to Avoid

• Do not transfuse FFP based solely on PT/INR prolongation in cirrhotic patients with stable hemoglobin and controlled bleeding, as PT is a poor stand-alone test to guide transfusion in chronic liver disease. 3
• Do not discontinue her cardiac or diabetes medications without cardiology consultation, as her CHF and IDDM require ongoing management and abrupt changes could precipitate decompensation. 2
• Do not overlook screening for hereditary hemorrhagic telangiectasia (HHT) if she has recurrent bilateral nosebleeds or family history of recurrent epistaxis; ENT should assess for oral/nasal telangiectasias. 1, 4
• Do not delay ENT referral beyond 30 days, as adequate follow-up allows assessment for underlying conditions when bleeding recurs. 1