A 65-year-old man presents to the emergency department because of a nosebleed, which started 6 hours ago. He has not been able to stop it with recumbency and nasal pressure. He had a similar nosebleed 2 years ago and was told by an ENT physician that he has telangiectasias in his nasal septum. He has not noted any bleeding or bruising elsewhere. There is no history of aspirin use, although he has taken a few ibuprofens recently. He is known to have chronic kidney disease with a serum creatinine of 6.8 mg/dL. A fistula has been placed in his arm anticipating the commencement of dialysis soon. He has hypertension, hyperlipidemia, osteoarthritis, and gout. Current medications include atenolol, amlodipine, calcium carbonate, reduced-dose allopurinol, and furosemide.
His blood pressure is 142/86 mm Hg without orthostatic changes, pulse is 84/min, and respirations are 16/min. Bright red blood is seen oozing around his left naris, which is filled with bloody tissue paper. Some bright red blood is seen in his posterior pharynx. His lung, cardiovascular, and abdominal exams are normal. There is no edema.
The patients labs reveal:

After anterior and posterior nasal packing, oozing into and around the packing continues.
Which of the following is the most appropriate next step in management?

Question

A 65-year-old man presents to the emergency department because of a nosebleed, which started 6 hours ago.  He has not been able to stop it with recumbency and nasal pressure.  He had a similar nosebleed 2 years ago and was told by an ENT physician that he has telangiectasias in his nasal septum.  He has not noted any bleeding or bruising elsewhere.  There is no history of aspirin use, although he has taken a few ibuprofens recently.  He is known to have chronic kidney disease with a serum creatinine of 6.8 mg/dL.  A fistula has been placed in his arm anticipating the commencement of dialysis soon.  He has hypertension, hyperlipidemia, osteoarthritis, and gout.  Current medications include atenolol, amlodipine, calcium carbonate, reduced-dose allopurinol, and furosemide.
His blood pressure is 142/86 mm Hg without orthostatic changes, pulse is 84/min, and respirations are 16/min.  Bright red blood is seen oozing around his left naris, which is filled with bloody tissue paper.  Some bright red blood is seen in his posterior pharynx.  His lung, cardiovascular, and abdominal exams are normal.  There is no edema.
The patients labs reveal:

After anterior and posterior nasal packing, oozing into and around the packing continues.
Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient with advanced-stage chronic kidney disease (CKD) has a bleeding disorder that may be related to his renal failure. The bleeding tendency in CKD is multifactorial, but likely results from defects in platelet and von Willebrand factor interaction when forming a hemostatic platelet plug. The degree of uremia does not correlate with bleeding risk, and coagulation studies (PT/PTT) and platelet counts may both be normal. The bleeding time, however, is often prolonged. 11ec193a_96a7_ceef_853d_411a05d7020c_MD0002_00 The table above summarizes the recommended treatments for uremic patients with active bleeding or for those about to undergo a surgical procedure. No treatment is required for asymptomatic patients. DDAVP is the simplest and least toxic treatment for acute bleeding and can be administered intravenously (preferred), subcutaneously, or intranasally. DDAVP works within 1 hour of administration, but only lasts 4-24 hours. Repeated doses are less effective, likely due to depletion of endothelial multimer stores. (Choice A) Cryoprecipitate can act quickly to improve renal failure bleeding, but it is not the preferred treatment due to risks of increased volume and possible exposure to blood borne pathogens. (Choice C) Urgent hemodialysis is usually done with some type of anticoagulation to prevent clotting in the extracorporeal circuit, which could worsen the epistaxis. While urgent dialysis can be done with minimal anticoagulation exposure, a single dialysis session only partially corrects the bleeding time and is unlikely to completely reverse the platelet defect. (Choice D) Conjugated estrogen is a second-line treatment if DDAVP does not stop the bleeding. However, estrogen may take up to 4-5 days to reach peak levels; thus, it is typically used to control the more prolonged bleeding. (Choice E) The prolonged bleeding time seen in CKD partially improves with an increase in the hematocrit from either transfusion or erythropoietin administration. Most responses occur in patients with a hematocrit less than 30%. This patient is hemodynamically stable, has a hematocrit greater than 30%, and would benefit less from a transfusion. Educational objective: This patient with advanced-stage chronic kidney disease (CKD) has a bleeding disorder that may be related to his renal failure. The bleeding tendency in CKD is multifactorial, but likely results from defects in platelet and von Willebrand factor interaction when forming a hemostatic platelet plug. The degree of uremia does not correlate with bleeding risk, and coagulation studies (PT/PTT) and platelet counts may both be normal. The bleeding time, however, is often prolonged. __________ References: Evidence-based treatment for uremic bleeding (http://www.ncbi.nlm.nih.gov/pubmed/17322926)

A 65-Year-Old Man Presents to the Emergency Department Because of a Nosebleed