Facial trauma with life-threatening bleeding treated by andexanet alfa administration: A case report

Recently, anticoagulant reversal has become a treatment option for life-threatening bleeding, especially in intracranial hemorrhage. Although evidence of the beneficial efficacy of andexanet alfa accumulates in cases of intracranial hemorrhage, little is known about its effectiveness in head injuries without intracranial hemorrhage. We present the case of an 87-year-old man who suffered a stroke 1 year previously and had been taking apixaban since then, who was brought to the emergency department with facial trauma due to a fall. Upon arrival at the hospital, the patient was conscious, and his vital signs were normal; however, physical examination revealed epistaxis, and plain head computed tomography (CT) showed multiple facial fractures without intracranial hemorrhage. As epistaxis was challenging to control, upper airway obstruction developed. His percutaneous oxygen saturation (SpO₂) decreased rapidly, and he underwent tracheal intubation. Contrast-enhanced head CT revealed at least two extravasations, near the anterior wall of the right maxillary sinus and from the nasal canal to the nasopharynx area. However, embolization using interventional radiology was deemed difficult. Because the bleeding did not stop, we determined the bleeding was life-threatening and uncontrollable. Therefore, we infused andexanet alfa to stop the bleeding. After infusion, hemostasis was confirmed. This case suggests the effectiveness of andexanet alfa in cases of facial trauma and extracranial bleeding difficult to stop, resulting in favorable outcomes and hemostatic effects.