SAQ 411 – ENT – epistaxis on warfarin

ENT – epistaxis on warfarin.

a. History

• Estimate blood loss: duration, number of soaked tissues, and swallowed blood.
• Effects of blood loss: dizziness, sweating, pallor, dyspnoea, or chest pain.
• Indication for warfarin, as prosthetic valve status affects reversal decisions.
• Comorbidities, especially uncontrolled hypertension.
• Social circumstances, competence, resources at home, and expectations.
• Medication history, including antiplatelets, antibiotics that raise INR, and allergies.

b. Control of epistaxis

• Reassure, sit upright, and apply firm external pressure to the nares while equipment is prepared.
• Suction blood and clots from the nostril.
• Apply a topical vasoconstrictor/local anaesthetic, such as adrenaline/lignocaine or cophenylcaine, to Little's area.
• Use chemical cautery with silver nitrate if the site is visible.
• If bleeding persists, pack anteriorly with gauze or another appropriate anterior pack.
• Optimise INR and reverse warfarin with vitamin K if appropriate, balancing the indication for anticoagulation.

c. Discharge advice

• Do not pick or blow the nose for at least four days; moisturise the nostrils with Vaseline or chloramphenicol ointment if advised.
• If warfarin is withheld, arrange repeat INR and review for restarting it.
• Return to ED for recurrent bleeding or for pack review/removal if a pack is in place.