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A 75-year-old man presents to the emergency department with profuse bleeding from nares for the past 2 hours. He states that he frequently has had nosebleeds but has never had to come into the emergency department before because they would go away when he pinched his nose; however, that did not work for this episode. His medical history includes diabetes, hypertension, and atrial fibrillation. His medications include glipizide, lisinopril, and warfarin (Coumadin). He is anxious, his blood pressure is 179/90 mm Hg, he has mild tachycardia at 102/min, and he has persistent bleeding from both nares. He has also been spitting blood from his mouth since this bleeding started.
Which of the following is the best next step in management?
A.Bilateral nasal packing
B.Blood transfusion (packed RBCs)
C.Fresh frozen plasma
D.Intramuscular vitamin K
E.Intravenous vitamin K
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yes
This patient has an active nasal bleed that has not resolved with direct pressure. Furthermore, he is on warfarin and thus has an impaired ability to clot. Nasal packing will stop this acute bleed and allow the nasal mucosa to remucosalize.
B is not correct. 2% chose this.
A blood transfusion will not stop his bleeding. A complete blood cell count should be checked to see if this patient does in fact need a transfusion, but it is more important to stop his acute bleeding.
C is not correct. 35% chose this.
Fresh frozen plasma will help to slow the bleeding by repleting his clotting factors if his International Normalized Ratio is elevated. However, nasal packing will stop the bleeding faster, and in acute bleeding, speed is vital.
D is not correct. 10% chose this.
Vitamin K can be given to reverse of the effects of warfarin. Warfarin competitively inhibits the actions of vitamin K in the liver's synthesis of clotting factors. Vitamin K works by overcoming that inhibition and allowing the liver to manufacture those clotting factors. As it takes the liver hours to days to manufacture these factors, vitamin K is not as useful in the acute setting as direct pressure on the site of the bleeding.
E is not correct. 9% chose this.
Vitamin K can be given to reverse of the effects of warfarin. Warfarin competitively inhibits the actions of vitamin K in the liver's synthesis of clotting factors. Vitamin K works by overcoming that inhibition and allowing the liver to manufacture those clotting factors. As it takes the liver hours to days to manufacture these factors, vitamin K is not as useful in the acute setting as direct pressure on the site of the bleeding.
Bottom Line:
The best treatment for any acute bleeding is direct pressure on the bleeding site, followed by transfusion with intravenous fluids, packed RBCs, and/or clotting factors as needed.
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but its scary taht if we had this question on the real exam we wud have chosen C and gotten it wrong...
thats why i love doing questions.
