From the Guidelines
Epistaxis, or nosebleed, should be initially managed at home by staying calm, sitting upright, leaning slightly forward, and pinching the soft part of the nose firmly for 10-15 minutes without releasing, as recommended by the most recent clinical practice guideline 1. This approach is based on the understanding that most nosebleeds are limited in severity and duration, and can be effectively managed with self-treatment and home remedies.
- Key steps in managing epistaxis at home include:
- Applying an ice pack to the bridge of the nose to constrict blood vessels
- Using saline nasal sprays or petroleum jelly inside the nostrils to keep the nasal passages moist
- Avoiding picking the nose, blowing forcefully, or inserting objects into the nasal passages
- It is essential to seek immediate medical attention if bleeding persists beyond 20-30 minutes, is extremely heavy, or occurs after head trauma, as these cases may require more intensive medical interventions 1.
- For patients with recurrent nosebleeds, particularly those with hereditary hemorrhagic telangiectasia (HHT), systemic therapies such as oral tranexamic acid may be recommended as an option for management of epistaxis that does not respond to moisturizing topical therapies alone 1.
- The use of tranexamic acid has been shown to reduce the duration and intensity of epistaxis in HHT patients, with a 17.3% reduction in the duration of epistaxis per month and a 54% reduction in a composite epistaxis end point 1.
From the Research
Definition and Prevalence of Epistaxis
- Epistaxis, also known as nosebleed, is a common emergency that affects up to 60% of the general population, with 6% seeking medical attention for it 2.
- The majority of episodes are managed at home with simple measures, but in more severe cases, medical intervention is required 3.
Management of Epistaxis
- Compressive therapy is the first step to controlling anterior epistaxis, and oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 may be useful adjuncts to compressive therapy 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 Tranexamic Acid in Epistaxis
- Tranexamic acid is used in a number of clinical settings to stop bleeding by preventing clot breakdown (fibrinolysis), and it may have a role in the management of epistaxis as an adjunct to standard treatments, reducing the need for further intervention 3.
- There is moderate-quality evidence that tranexamic acid reduces the risk of re-bleeding in adult patients with epistaxis, compared to placebo with usual care 3.
- Topical tranexamic acid is probably better than other topical agents in stopping bleeding in the first 10 minutes, but the quality of evidence relating solely to topical tranexamic acid is low 3.
Comparison of Treatments for Epistaxis
- Oxymetazoline is superior to tranexamic acid and epinephrine-lidocaine in achieving rapid hemostasis and reducing recurrence in epistaxis 4.
- The topical application of the intravenous preparation of tranexamic acid is more effective than topical oxymetazoline for achievement of hemostasis in anterior epistaxis 5.
- Pharmacologic management with oxymetazoline may be adequate in the majority of patients with epistaxis, thus avoiding the need for nasal packing with its associated complications 6.