What are the interventions for epistaxis (nose bleed)?

From the Guidelines

Interventions for epistaxis (nosebleed) should prioritize first-line measures such as direct pressure, ice or cold compresses, and over-the-counter nasal decongestant sprays, with advanced treatments like chemical cauterization, nasal packing, and endoscopic cauterization reserved for persistent or severe cases, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1.

Initial Management

For initial management, the following steps can be taken:

• Apply direct pressure by pinching the soft part of the nose firmly for 10-15 minutes while leaning slightly forward to prevent blood from flowing down the throat.
• Apply ice or cold compresses to the bridge of the nose to promote vasoconstriction.
• Use over-the-counter nasal decongestant sprays containing oxymetazoline (such as Afrin) temporarily to constrict blood vessels, but avoid using them for more than 3 days to prevent rebound congestion.

Advanced Treatments

For persistent bleeding, medical professionals may use:

• Chemical cauterization with silver nitrate sticks.
• Hemostatic materials like Surgicel or Gelfoam.
• Nasal packing with specialized devices such as Merocel or Rapid Rhino balloons, which typically remain in place for 24-72 hours. Severe or recurrent cases may require:
• Endoscopic cauterization of the bleeding vessel.
• Arterial ligation procedures targeting the sphenopalatine or ethmoidal arteries.
• Embolization performed by interventional radiology.

Underlying Conditions

Underlying conditions contributing to nosebleeds should be addressed, including:

• Hypertension management.
• Discontinuation of blood thinners when appropriate.
• Treatment of coagulation disorders. Maintaining nasal mucosa hydration with saline sprays and petroleum jelly can help prevent recurrence, as dry nasal passages are more prone to bleeding 1.

From the Research

Interventions for Epistaxis

Interventions for epistaxis (nose bleed) can be categorized into several types, including:

• First aid measures
• Topical agents
• Cauterization
• Nasal packing
• Endoscopic methods
• Embolization

First Aid Measures

First aid measures for epistaxis include:

• External pressure and ice packing 2
• Compressive therapy, which is the first step to controlling anterior epistaxis 3
• Direct pressure to the nasal alae for 15 minutes 4

Topical Agents

Topical agents used to treat epistaxis include:

• Oxymetazoline, which stops 65-75% of nosebleeds in A&E 2 and is superior to tranexamic acid and epinephrine-lidocaine in achieving rapid hemostasis and reducing recurrence in epistaxis 4
• Tranexamic acid, which promotes hemostasis in 78% of patients 2 and is more effective than topical oxymetazoline for achievement of hemostasis in anterior epistaxis 5
• Epinephrine-lidocaine combination, which is less effective than oxymetazoline in achieving hemostasis 4

Cauterization

Cauterization methods used to treat epistaxis include:

• Electrocautery, which is more effective and has fewer recurrences than chemical cauterization 2
• Chemical cauterization, which is less effective than electrocautery 2
• Silver nitrate cautery, which can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 3

Nasal Packing

Nasal packing can be applied with:

• Non-absorbable materials, such as petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, and balloons (Rapid-Rhino) 2
• Absorbable materials, such as nasal tampon (Nasopore) 2
• Newer hemostatic materials, such as hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan), and fibrin glue, which are more effective and have fewer complications than traditional methods 2

Endoscopic Methods

Endoscopic methods used to treat epistaxis include:

• Endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing 2
• Endoscopic cauterization, which is more effective than ligation 2

Embolization

Embolization can be applied using:

• Gelatin sponge, foam, PVA, and coils, with an 80% success rate and comparable efficacy and complications to surgical methods 2