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

From the Guidelines

The initial management of epistaxis involves having the patient sit down and continuously hold the lower third or soft portion of the nose pinched closed 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 supported by the most recent and highest quality studies, which emphasize the importance of direct pressure in controlling bleeding and promoting clot formation. The patient should be instructed to breathe through their mouth and spit out any blood, and to lean forward to prevent blood from entering the airway or stomach. Key considerations in the management of epistaxis include:

• Control of acute bleeding
• Prevention of recurrent episodes of nasal bleeding
• Complications of treatment modalities
• Accuracy of diagnostic measures
• Management of underlying causes, such as hypertension or hereditary hemorrhagic telangiectasia syndrome
• Reversal strategies for anticoagulation and antiplatelet medications, if applicable
• Nasal endoscopy to localize the bleeding site and exclude foreign bodies or other intranasal pathology. According to the clinical practice guideline: nosebleed (epistaxis) executive summary 1, interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. The guideline also emphasizes the importance of good local control efforts, including nasal compression, vasoconstrictors, moisturizing or lubricating agents, nasal cautery, and/or nasal packing, before considering reversal strategies for anticoagulation and antiplatelet medications 1. In cases where bleeding is severe or persistent, further evaluation and management may be necessary, including nasal endoscopy and targeted therapy 1.

From the Research

Initial Management Approach for Epistaxis

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

• Assessment of vital signs, mental status, and airway patency 2
• Compressive therapy as the first step to controlling anterior epistaxis 2
• Use of oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 as adjuncts to compressive therapy 2, 3
• Directive nasal cautery using silver nitrate to control localized continued bleeding or prominent vessels 2
• Topical therapy and nasal packing if other methods are unsuccessful 2

Treatment Options

Various treatment options are available for epistaxis, including:

• First aid measures such as external pressure and ice packing 4
• Topical agents like oxymetazoline that can stop 65-75% of nosebleeds in A&E 4
• Electrocautery, which is more effective and has fewer recurrences than chemical cauterization 4
• Tranexamic acid, which promotes hemostasis in 78% of patients 4
• Nasal packing with non-absorbable or absorbable materials 4, 2
• Endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing 4
• Endoscopic cauterization, which is more effective than ligation 4
• Embolization using gelatin sponge, foam, PVA, and coils with an 80% success rate 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
• Identification of the bleeding source and determination of the best course of treatment 2