What is the initial management for a patient presenting with epistaxis?

From the Guidelines

The initial management for a patient presenting with epistaxis should involve sitting with their head slightly forward with their nostrils pinched for 10 to 15 minutes, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. This approach is based on the strongest and most recent evidence, which emphasizes the importance of direct pressure to control bleeding.

• Key considerations for initial management include:
  • Sitting with the head slightly forward to prevent blood from flowing down the throat
  • Pinching the nostrils for 10 to 15 minutes to apply direct pressure to the bleeding vessels
  • Seeking medical attention if bleeding does not stop after 15 minutes of continuous manual pressure or if the patient becomes lightheaded 1
• Additional factors to consider in the management of epistaxis include:
  • The use of anticoagulant or antiplatelet medication, or the presence of a blood-clotting disorder, which may necessitate seeking care from a healthcare professional unless bleeding has stopped 1
  • The potential for trauma-related epistaxis, which may require medical attention if signs of brain injury, obvious nasal deformity, or signs of facial fracture are present 1
• It is essential to prioritize these evidence-based recommendations to ensure optimal outcomes in terms of morbidity, mortality, and quality of life for patients presenting with epistaxis.

From the Research

Initial Management of Epistaxis

The initial management of a patient presenting with epistaxis involves several steps, including:

• Assessment of vital signs, mental status, and airway patency 2
• Application of compressive therapy to control anterior epistaxis 2
• Use of adjuncts such as oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 to aid in compressive therapy 2
• Directive nasal cautery using silver nitrate for localized continued bleeding or prominent vessels 2

Treatment Options

Various treatment options are available for epistaxis, including:

• Topical agents such as oxymetazoline, which can stop 65-75% of nosebleeds in the emergency department 3
• Tranexamic acid, which promotes hemostasis in 78% of patients 3
• Nasal packing with non-absorbable or absorbable materials, such as petroleum jelly, BIPP gauze, or nasal tampons 3
• Endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing 3
• Endoscopic cauterization, which is more effective than ligation 3
• Embolization using gelatin sponge, foam, PVA, and coils, with an 80% success rate 3

Comparison of Treatment Efficacy

A study comparing the efficacy of oxymetazoline, tranexamic acid, and epinephrine-lidocaine combination in the treatment of epistaxis found that:

• Oxymetazoline achieved hemostasis in 71% of patients, compared to 55% for tranexamic acid and 49% for epinephrine-lidocaine 4
• Oxymetazoline showed superior efficacy in achieving rapid hemostasis and reducing recurrence in epistaxis 4

Patient Evaluation

Evaluation of a patient presenting with epistaxis should begin with:

• Assessment of vital signs, mental status, and airway patency 2
• Examination of the nose using a nasal speculum and a good light source, such as a headlamp 2