What are the steps to manage epistaxis (nosebleed)?

From the Guidelines

To stop a bloody nose, first sit down and lean slightly forward, not backward, to prevent blood from flowing down your throat, and pinch the soft part of your nose shut with your thumb and index finger, applying steady pressure for 10-15 minutes without releasing or checking if bleeding has stopped, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.

Step-by-Step Instructions

• Sit down and lean slightly forward to prevent blood from entering the airway or stomach.
• Pinch the soft part of your nose shut with your thumb and index finger, applying steady pressure for 10-15 minutes without releasing or checking if bleeding has stopped.
• Breathe through your mouth during this time to avoid swallowing blood.
• If bleeding persists beyond 20 minutes, is extremely heavy, follows a head injury, or if you experience frequent nosebleeds, seek medical attention, as advised by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.

Prevention of Future Nosebleeds

• Keep your nasal passages moist with saline sprays or petroleum jelly to prevent dryness and irritation.
• Use a humidifier to add moisture to the air, especially in dry environments.
• Avoid picking or blowing your nose, and avoid hot or spicy foods for 24 hours after the bleeding stops to prevent recurrence.

Important Considerations

• Nasal pressure alone is often sufficient to stop bleeding, and other interventions may not be necessary, as stated in the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
• If you are taking anticoagulant or antiplatelet medication, or have a blood-clotting disorder, it is reasonable to seek care from a healthcare professional if bleeding does not stop, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.

From the Research

Step-by-Step Management of Bloody Nose

To manage a bloody nose, the following steps can be taken:

• Apply compressive therapy to control anterior epistaxis 2
• Use oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 as adjuncts to compressive therapy 2
• Perform directive nasal cautery using silver nitrate to control localized continued bleeding or prominent vessels 3, 2, 4
• Use topical therapy and nasal packing if other methods are unsuccessful 2, 4
• Consider using inflatable anterior nasal balloon packs or a Foley catheter nasopharyngeal balloon pack for posterior epistaxis 4

Additional Considerations

• Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency 2
• Use of a nasal speculum and a good light source, such as a headlamp, can be useful when examining the nose 2
• Appropriate anesthetic and analgesics can lessen the unpleasantness for both the patient and the provider 4
• Topical moisturizing can facilitate mucosal healing 4
• Oxymetazoline 0.05% nasal spray can provide the patient with means to address rebleeding after discharge from treatment 4

Comparison of Management Strategies

• Nonpacking interventions, such as cauterization, embolization, and ligation, may be associated with increased hospital charges and length of stay, but not increased morbidity or mortality 5
• Embolization may result in greater hospital charges, but no change in outcome when compared to ligation 5
• Nasal packing may be necessary in some cases, but can be associated with pain and a risk of aspiration if dislodged 5, 2