MedBugs: SAQ #248

Case: Epistaxis on apixaban

A 76-year-old man self-presents to the Emergency Department with epistaxis. He describes on and off bleeding for most of the preceding day that has become heavier over the past hour. He has a past medical history of hypertension and atrial fibrillation on apixaban. His observations are : HR 114/min (AF) BP 167/95 RR 14 Sats 95%RA Bleeding does not settle with first aid measures. You are concerned that the source of bleeding is posterior. The patient is now pale. Updated vitals are as follows : HR 154/min (AF) BP 98/65 Despite insertion of a Rapid Rhino, the bleeding remains uncontrolled. Your provision blood investigations return the following results : PT 11.5 (11.0-13.5sec) INR 0.9 (0.8-1.1) aPTT 32 (30-40sec)

1. State 4 initial first aid or topical measures that can be used to control anterior epistaxis. 4 marks

2. List factors on physical examination that suggests a posterior source of bleeding. 3 marks

Despite insertion of a Rapid Rhino, the bleeding remains uncontrolled.

3. List definitive treatment options for haemorrhage control in posterior epistaxis. 2 marks

Your provision blood investigations return the following results : PT 11.5 (11.0-13.5sec) INR 0.9 (0.8-1.1) aPTT 32 (30-40sec)

4. How do you interpret these coagulation parameters in a patient taking apixaban? 2 marks

5. List steps in the management of life-threatening bleeding in a patient taking apixaban. 5 marks

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