SAQ 461 – ENT – epistaxis and warfarin reversal

ENT – epistaxis and warfarin reversal.

a. History

• Duration, estimated blood loss, number of tissues/towels soaked and swallowed blood.
• Precipitant such as trauma, nose-picking, recent procedure or spontaneous onset.
• Previous episodes and treatments.
• Symptoms of blood loss such as dizziness, dyspnoea, sweating, pallor or chest pain.
• Anticoagulants and antiplatelets, including warfarin, DOACs, aspirin and clopidogrel.
• Comorbidities such as hypertension, liver disease, bleeding disorder or malignancy.
• Reason for anticoagulation and thrombotic risk.
• Social supports, ability to comply with packing/follow-up, expectations and goals of care.

b. Haemostasis

• Sit forward, reassure, apply firm continuous pressure and prepare equipment.
• Suction blood and remove clots to identify the bleeding point.
• Apply topical vasoconstrictor and local anaesthetic, for example co-phenylcaine or lignocaine/adrenaline.
• Cauterise a visible anterior bleeding point with silver nitrate.
• If bleeding persists, insert an anterior nasal pack and correct coagulopathy; escalate to ENT for posterior bleeding or failed packing.

c. Warfarin reversal

• Stop warfarin and follow local major-bleeding protocol.
• Give IV vitamin K 5-10 mg.
• Give prothrombin complex concentrate, for example 35-50 units/kg depending on INR and protocol.
• Use FFP if bleeding is life-threatening and PCC is unavailable or inadequate, then repeat INR and reassess.