Rosh Review My EMCert Monthly Question

A 67-year-old woman with a history of atrial fibrillation on apixaban presents to the ED for epistaxis that began 30 minutes ago. Her bleeding is difficult to control with direct nasal pressure and topical agents but resolves with silver nitrate cauterization. Her vital signs are within normal limits. How should this patient’s apixaban be managed?

1. Administer a one-time dose of intravenous vitamin K
2. Administer andexanet alfa
3. Bolus 1 unit of prothrombin complex concentrate
4. Give intravenous tranexamic acid
5. Hold her next dose of apixaban

References

1. Garcia DA, Crowther M. Management of bleeding in patients receiving direct oral anticoagulants. Post TW, ed. UpToDate. UpToDate Inc. Accessed July 19, 2022. https://www.uptodate.com/contents/management-of-bleeding-in-patients-receiving-direct-oral-anticoagulants
2. McGinnis HD. Nose and sinuses. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw Hill; 2020(Ch) 244. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221179919
3. Slattery DE, Pollack CV Jr. Thrombotics and antithrombotics. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw Hill; 2020:(Ch) 239. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221179142

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Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)