What is the treatment for epistaxis (nose bleeding)?

From the Guidelines

To treat a nosebleed, the most effective initial approach is to sit upright, lean slightly forward, and pinch the soft part of the nose firmly between the thumb and index finger for 10 to 15 minutes continuously without releasing pressure or checking if bleeding has stopped, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. This method is supported by the highest quality and most recent evidence, which emphasizes the importance of continuous manual pressure in managing epistaxis.

Key Considerations

• The person experiencing epistaxis should breathe through their mouth and spit out any blood to prevent it from entering the airway or stomach.
• If bleeding persists after 15 minutes of continuous manual pressure or if the person becomes lightheaded, they should seek medical attention 1.
• For individuals taking anticoagulant or antiplatelet medication, or those with a blood-clotting disorder, it is reasonable to seek care from a healthcare professional unless bleeding has stopped 1.

Additional Measures

• Applying an ice pack or cold compress to the bridge of the nose may help constrict blood vessels, although its usefulness in the first aid setting is unknown 1.
• For recurrent nosebleeds, keeping the nasal passages moist with petroleum jelly (Vaseline) or saline nasal sprays can help prevent additional bleeding.
• Avoiding actions that can irritate the nasal passages, such as picking the nose, blowing forcefully, or inserting objects into the nostrils, is also important.

Medical Intervention

• If nosebleeds are frequent or severe, especially in individuals on anticoagulants, consulting a healthcare provider for potential cauterization or packing may be necessary.
• The use of topical treatments, including vasoconstricting agents like oxymetazoline or phenylephrine, and nasal cautery, may be considered in certain cases, as outlined in the clinical practice guideline for nosebleed (epistaxis) management 1.

From the Research

Treatment Options for Nose Bleeding

• Compressive therapy is the first step to controlling anterior epistaxis, with oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 as useful adjuncts 2
• Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 2
• Topical therapy and nasal packing can be used if other methods are unsuccessful, with posterior nasal packing often associated with pain and a risk of aspiration if it is dislodged 2
• Use of an intranasal vasoconstrictor (oxymetazoline) can be used to effectively treat epistaxis, avoiding nasal packing, with 65% of patients successfully managed with oxymetazoline as their sole therapy 3
• Management options also include topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention 4

Specific Considerations

• Anterior epistaxis is more common and can often be treated in the outpatient setting, while posterior epistaxis is more likely to require hospitalization and nasal packing 2, 4
• Risk factors for epistaxis include local trauma, foreign body insertion, substance abuse, neoplasms, inherited bleeding diatheses, or acquired coagulopathies 4
• Assessment of airway, breathing, and circulation precedes identification of bleeding source, pain control, and achieving hemostasis 4