What is the initial management of a patient presenting with epistaxis (nosebleed)?

From the Guidelines

The initial management of epistaxis involves applying direct pressure to the anterior part of the nose by pinching the soft part of the nostrils together continuously for 10-15 minutes while the patient sits upright and leans slightly forward, as recommended by the most recent clinical practice guideline 1. This position prevents blood from flowing down the throat. The patient should breathe through the mouth during this time.

Initial Assessment and Management

If bleeding persists, applying a vasoconstrictor such as oxymetazoline (Afrin) nasal spray can help constrict blood vessels, with studies reporting that 65% to 75% of patients have resolution of nasal bleeding with oxymetazoline 1. Cold compresses on the bridge of the nose may also assist in vasoconstriction. For more persistent bleeding, nasal packing with materials such as Merocel or ribbon gauze soaked in antibiotic ointment may be necessary. If the patient is on anticoagulants, these medications may need to be temporarily held after consultation with the prescribing physician, as patients taking these medications are more likely to present with recurrent epistaxis, have a large volume of blood loss, and require blood transfusion for treatment 1. Patients with hypertension should have their blood pressure controlled, as elevated pressure can worsen bleeding. Most nosebleeds originate from Kiesselbach's plexus in the anterior nasal septum, and direct pressure works because it compresses the bleeding vessels against the septum, allowing clot formation. Severe or recurrent epistaxis may require cauterization with silver nitrate or electrocautery, or referral to an ENT specialist for more advanced interventions.

Differential Diagnosis and Workup

The differential diagnosis for epistaxis includes:

• Anterior nasal septum bleeding
• Posterior nasal bleeding
• Nasal masses or tumors
• Nasal foreign bodies
• Systemic hematologic, hepatic, renal, genetic, or cardiovascular diseases Nasal endoscopy may be indicated to evaluate for these conditions, particularly if bleeding was unusually difficult to control or if clinical symptoms or signs exist alerting the clinician to additional bleeding sites or intranasal pathology 1. With nasal endoscopy, the bleeding site can be localized in 87% to 93% of cases, and targeted therapy can be initiated accordingly. Posterior epistaxis can occur from locations on the septum or the lateral nasal wall, making targeted therapy difficult without endoscopic identification of the source of bleeding 1.

Special Considerations

Nosebleeds seem to affect the population in a bimodal age distribution, with more nosebleeds seen in children and the elderly, and patients aged > 85 years are 3.24 times more likely to present to the emergency room than patients < 65 years old 1. In children, nasal foreign bodies are a common issue, and delay in diagnosis is not uncommon, with epistaxis being the presenting symptom in 7% of patients with a nasal foreign body 1. In adolescent male patients, persistent or recurrent nasal bleeding could suggest the diagnosis of juvenile nasopharyngeal angiofibroma, an uncommon histologically benign but locally invasive vascular tumor 1.

From the Research

Differential Diagnosis of Epistaxis

• The differential diagnosis of epistaxis includes local trauma, foreign body insertion, substance abuse, neoplasms, inherited bleeding diatheses, or acquired coagulopathies 2
• Anticoagulant therapy is a main risk factor for epistaxis, with both vitamin K antagonists and direct oral anticoagulants increasing the risk of bleeding 3

Initial Management of Epistaxis

• The initial management of epistaxis involves assessment of vital signs, mental status, and airway patency 4
• 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 4
• 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 5, 4

Workup for Epistaxis

• Evaluation of a patient presenting with epistaxis should include examination of the nose using a nasal speculum and a good light source, such as a headlamp 4
• Identification of the bleeding source is crucial, with most anterior epistaxis originating from the Kiesselbach plexus and posterior epistaxis originating from branches of the sphenopalatine artery 2
• Laboratory tests, such as bloodwork, may be necessary to evaluate for underlying coagulopathies or other conditions that may be contributing to the epistaxis 3

Treatment Options for Epistaxis

• Treatment options for epistaxis include topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention 2
• Pharmacologic management, such as oxymetazoline, may be adequate in the majority of patients with epistaxis, avoiding the need for nasal packing 5
• Specialty consultation may be pursued if interventions fail, particularly in cases of posterior epistaxis or significant comorbidities 4, 2