What is the initial management of epistaxis?

From the Guidelines

The initial management of epistaxis should involve sitting with the head slightly forward and pinching the nostrils 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 study, which emphasizes the importance of direct pressure in controlling epistaxis. Some key points to consider in the management of epistaxis include:

• Applying direct pressure to the nostrils for an extended period
• Leaning forward to prevent blood from flowing down the throat
• Avoiding activities that may exacerbate bleeding, such as hot liquids, strenuous activity, nose picking, and blowing the nose
• Considering medical attention if bleeding persists or is severe, especially in individuals taking anticoagulant or antiplatelet medication, or with a blood-clotting disorder 1. It is also important to note that the usefulness of cryotherapy (ice) for managing epistaxis in the first aid setting is unknown, and therefore, its use is not recommended as a primary intervention 1. In cases where bleeding cannot be controlled with initial management, more advanced interventions such as nasal packing, cauterization, or endoscopic evaluation may be necessary, and medical attention should be sought immediately 1.

From the Research

Initial Management of Epistaxis

The initial management of epistaxis involves several steps and treatment options, including:

• First aid measures such as external pressure and ice packing to control bleeding 2
• Application of topical agents, e.g. oxymetazoline, to stop bleeding 2
• Use of tranexamic acid to promote hemostasis 2, 3
• Nasal packing with non-absorbable or absorbable materials 2, 4
• Directive nasal cautery using silver nitrate to control localized bleeding 4

Treatment Options

Treatment options for epistaxis include:

• Topical application of injection tranexamic acid, which has been shown to reduce bleeding time and number of rebleeds compared to anterior nasal packing 5
• Anterior nasal packing with gel foam, which is a common treatment modality for epistaxis 5
• 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 using gelatin sponge, foam, PVA, and coils, which has a success rate of 80% and comparable efficacy and complications to surgical methods 2

Patient Outcomes

Patient outcomes after treatment for epistaxis include:

• Recurrence of bleeding, which is common and may occur soon after initial discharge 6
• Need for repeat treatment, which is required in 70% of patients who return to the emergency room 6
• Use of tobacco and chronic use of acetylsalicylic acid, which are associated with an increased risk of recurrence 6