This systematic review looks at the increasing complexity in this space as anti-thrombotics become more sophisticated and move away from the more well understood management of warfarinised patients. After a thorough search, 29 papers were found to be relevant and some international and national guidelines utilised also. A third of all ENT emergency admissions in the UK are due to epistaxis, that’s 20,000 a year and 60% are on some form of anti-thrombotic therapy. A risk assessment should be undertaken for which there is little guidance, although patients with a cardiac stent, recent thromboembolism or a heart valve would seem to be most at risk of stopping their anticoagulants. The rate of stroke in patients with atrial fibrillation or metallic valve who stop their anticoagulants for five days is 1.5:1000. In those with a previous history of stroke it’s three times higher. Clotting studies are only valuable in those taking a warfarin-type anticoagulant or those with recurrent or moderate to severe bleeding; the advice of a haematologist should be sought for those on new anticoagulants.
There may be a role for topical tranexamic acid, a plasminogen binder, but no data to support systemic use, despite the widespread use of this drug. Withdrawal of anti-platelet drugs such as Clopidrogel is unlikely to help in the acute setting with epistaxis. Its metabolite will also continue to affect both transfused and new platelets.
There is currently no evidence to support platelet transfusion in epistaxis. Vitamin K antagonists such as warfarin can be continued if bleeding is controlled, although if supra therapeutic should be ceased. INR of 6 should be reversed with Vitamin K, 1-2mg IV. If life threatening, prothrombin complex concentrate should also be given. Direct oral anticoagulants have a short half-life of 812 hours and withholding them can be very effective, dabigatran can be reversed with charcoal, dialysis and idarucizumab. Again, prothrombin complex concentrate should be used if life threatening. This area has changed and become very complex, patients should be discussed with a haematologist and cardiologist for the most up-to-date advice.
