From the Guidelines
The initial management of epistaxis involves sitting with the head slightly forward and pinching the nostrils 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 aimed at reducing blood flow to the nasal vessels and preventing aspiration of blood. The patient should be advised to breathe through the mouth during this time. Key considerations in the management of epistaxis include:
- Applying direct pressure to the anterior part of the nose
- Sitting upright with a slight forward lean
- Breathing through the mouth
- Avoiding nose-picking, forceful nose-blowing, and strenuous activity for 24-48 hours after the bleeding stops to prevent recurrence. If bleeding persists after 15 minutes of continuous manual pressure, or if the patient becomes lightheaded, seeking medical attention is recommended 1. Additionally, patients with epistaxis due to trauma should seek medical attention if they experience signs of brain injury, obvious nasal deformity, or signs of facial fracture 1. For patients taking anticoagulant or antiplatelet medication, or who have a blood-clotting disorder, seeking care from a healthcare professional is reasonable unless bleeding has stopped 1. The use of cryotherapy (ice) for managing epistaxis in the first aid setting is unknown 1. Overall, the management of epistaxis should prioritize reducing blood flow, preventing aspiration, and promoting patient safety, with consideration of individual patient factors and circumstances.
From the Research
Initial Management of Epistaxis
The initial management of a patient presenting with epistaxis (nosebleed) involves several steps, including:
- Assessment of vital signs, mental status, and airway patency 2
- Application of compressive therapy, such as external pressure and ice packing, to control anterior epistaxis 2, 3
- Use of topical agents, such as oxymetazoline, to stop bleeding 3, 4, 5
- Directive nasal cautery, using silver nitrate, to control localized continued bleeding or prominent vessels 2
Treatment Options
Various treatment options are available for epistaxis, including:
- Topical therapy, such as oxymetazoline, tranexamic acid, and epinephrine-lidocaine combination 5
- Nasal packing, using non-absorbable or absorbable materials 3, 2
- Electrocautery, which is more effective and has fewer recurrences than chemical cauterization 3
- Endoscopic ligation of arteries, mainly SPA, which is more effective than conventional nasal packing 3
- Embolization, using gelatin sponge, foam, PVA, and coils, with an 80% success rate 3
Effectiveness of Treatment Options
Studies have shown that:
- Oxymetazoline is effective in stopping 65-75% of nosebleeds in the emergency department 3
- Tranexamic acid promotes hemostasis in 78% of patients, versus 35% and 31% respectively in patients treated with oxymetazoline and nasal packing 3
- Oxymetazoline is superior to tranexamic acid and epinephrine-lidocaine in achieving rapid hemostasis and reducing recurrence in epistaxis 5