What is the treatment for epistaxis?

Treatment for Epistaxis (Nosebleed)

For active nosebleeds, the patient should sit with their head slightly forward and pinch the lower third (soft portion) of the nose firmly for 10-15 minutes continuously. 1

First Aid Management Algorithm

Immediate Steps for Active Bleeding

1. Position: Have the patient sit upright with head tilted slightly forward (not backward) 1

   • This prevents blood from entering the airway or stomach
   • Instruct the patient to breathe through the mouth and spit out any blood

2. Compression: Apply firm, sustained compression to the lower third (soft portion) of the nose for 10-15 minutes continuously 1

   • This allows time for blood to clot
   • Compression should be maintained without interruption
   • Nasal pressure alone resolves the vast majority of cases, including 20% of cases managed in emergency departments 1

3. Assessment: After 10-15 minutes, release pressure to check if bleeding has stopped

   • If bleeding continues, reapply compression for another 10-15 minutes

When to Seek Medical Attention

Medical attention should be sought if:

• Bleeding does not stop after 15 minutes of continuous manual pressure 1
• Patient becomes lightheaded from blood loss 1
• Epistaxis is due to trauma with signs of brain injury, nasal deformity, or facial fracture 1
• Patient is taking anticoagulant or antiplatelet medications (unless bleeding has stopped) 1

Medical Treatment Options

If first aid measures fail to control bleeding, medical interventions may include:

1. Topical vasoconstrictors: Medications like oxymetazoline can stop 65-75% of nosebleeds 2

2. Nasal cautery: After anesthesia, cauterization can be applied precisely to the bleeding site 1

   • Electrocautery appears more effective than chemical cautery 1
   • Bilateral cautery should be used cautiously to avoid septal perforation

3. Nasal packing: For ongoing active bleeding 1

   • Resorbable packing is preferred for patients with bleeding disorders or on anticoagulants 1

4. Tranexamic acid: Topical application has shown higher rates of bleeding control compared to nasal packing in some studies 1

Prevention of Recurrence

After bleeding has stopped, preventive measures include:

• Moisturizing/lubricating agents: Apply emollient creams or ointments to prevent recurrence 1
• Humidification: Use a humidifier to prevent nasal dryness
• Avoid digital trauma: Discourage nose picking and forceful nose blowing

Special Considerations

• Anticoagulant users: In the absence of life-threatening bleeding, first-line treatments should be initiated prior to reversal or withdrawal of anticoagulation 1
• Recurrent bilateral nosebleeds: May warrant assessment for nasal telangiectasias, especially with family history 1

Common Pitfalls to Avoid

1. Incorrect head position: Tilting the head backward can cause blood to flow into the throat, leading to aspiration or vomiting
2. Inadequate compression time: Releasing pressure too early before clotting occurs
3. Improper compression location: Compression must be on the soft lower third of the nose, not the bony upper portion
4. Using ice/cryotherapy: The usefulness of applying ice for epistaxis is unknown and not supported by evidence 1

Most nosebleeds can be effectively managed with proper compression technique, and only a small percentage (about 6%) require medical intervention 3.