A 74-year-old taking apixaban has ongoing posterior epistaxis despite resuscitation, correction of reversible factors and correctly placed packing. They are now haemodynamically stable. What is the most appropriate definitive next step in a centre with expertise?
Persistent posterior bleeding after appropriate packing is usually best addressed with directed endoscopic haemostasis; anticoagulant management must be coordinated, but stopping it alone is not definitive local control.
A. Repeat blind posterior packing for several days: This prolongs morbidity and delays source control.
B. External carotid ligation as first-line treatment: A targeted endoscopic approach is generally more direct and less morbid when available.
C. Discharge once haemoglobin is stable: A stable laboratory result does not establish haemostasis.
D. Anterior septal cautery alone: This is unlikely to control a true posterior source.
E. Endoscopic assessment and targeted sphenopalatine-artery control: Persistent posterior bleeding after appropriate packing is usually best addressed with directed endoscopic haemostasis; anticoagulant management must be coordinated, but stopping it alone is not definitive local control.
If endoscopy localised bleeding to the anterior ethmoidal territory, the vascular target and risk discussion would change.
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