HPI: 85 y.o. Male PMH Afib (on Warfarin) p/w epistaxis

• Constant x6 hours
• Bilateral nares
• No relief with applying pressure or with vasoconstrictors (Afrin) PTA

PHYSICAL EXAM

Vitals: BP 140/81  | Pulse 73  | Resp 18 | SpO2 96%

HENT: Epistaxis bilateral nares - unable to visualize source. Blood within oropharynx

DDX

• Anterior vs posterior epistaxis
• Acute blood loss anemia

WORK UP (LABS)

• CBC
• PT/INR

INITIAL PLAN

• Attempt to visualize source - have patient blow nose to blow out any clots
• Nasal speculum
• If no active hemorrhage and source visualized → silver nitrate cautery 
• Oxymetazoline (Afrin) nasal spray + pressure for 10 minutes
• Oxymetazoline (Afrin) + TXA soaked gauze for 20 minutes

LAB RESULTS AND REASSESS

• HGB 8.6
• INR 4.8

FINAL PLAN

• Warfarin (Coumadin) reversal → 2.5 mg phytonadione (vitamin K1)
• TXA soaked 5.5 cm Rhino Rocket 
• RESOLVED
• IF not → posterior packing required
• Admitted for observation, repeat CBC, INR, ENT consult
• Prophylactic antibiotics for TSS??
• Controversial!!
• Options: Cephalexin, Amoxicillin/clavulanate, Clindamycin

KEY POINTS

• Anterior epistaxis (most common!) → Kiesselbach’s Plexus
• Multiple options: TXA nebs, soaked gauze / pledgets (TXA, lidocaine w/ epinephrine, tetracaine, cocaine), nasal tampons, nasal balloons
• Posterior epistaxis
• Foley cath or other balloon devices
• Requires ICU for cardiac monitoring given risk for bradydysrhythmias 
• Consider anticoagulation reversal