What can I advise an 86-year-old patient with a 3-day history of epistaxis (nosebleeds) and no medications that could be causing the bleeding?

Management of Nosebleeds in an 86-Year-Old Patient

For an 86-year-old patient with a 3-day history of nosebleeds and no causative medications, first-line treatment should be firm sustained compression to the lower third of the nose for at least 5 minutes, followed by identification of the bleeding site and appropriate intervention such as topical vasoconstrictors, nasal cautery, or moisturizing agents. 1

Initial Assessment and Management

1. Assess severity and need for urgent care:

   • Check for signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension)
   • Evaluate airway patency and breathing
   • Determine if bleeding is active, recurrent, or stopped

2. First-line treatment for active bleeding:

   • Have the patient sit upright with head slightly forward
   • Apply firm sustained compression to the lower third (soft part) of the nose for at least 5 minutes 1
   • Instruct the patient to breathe through the mouth and spit out any blood

3. Identify the bleeding site:

   • Perform anterior rhinoscopy after removing any blood clots
   • Look for bleeding from Kiesselbach's plexus (most common site in anterior nasal cavity) 2

Treatment Options Based on Identified Bleeding Site

For Anterior Bleeding:

• Apply topical vasoconstrictors (oxymetazoline or phenylephrine) to the bleeding site 1
• Consider nasal cautery if a specific bleeding point is identified:
  • Anesthetize the site with topical lidocaine or tetracaine
  • Apply cautery only to the active bleeding site (silver nitrate is commonly used)
  • Avoid bilateral cautery to prevent septal perforation 1
• Apply moisturizing/lubricating agents after bleeding stops

For Posterior or Uncontrolled Bleeding:

• If bleeding persists despite compression and first-line measures, nasal packing may be necessary
• For elderly patients or those with suspected bleeding disorders, use resorbable packing 1
• Consider referral to an otolaryngologist if bleeding is severe, recurrent, or difficult to control

Risk Factor Assessment

Evaluate for factors that may increase bleeding severity or recurrence:

• Hypertension (common in elderly patients)
• Chronic kidney or liver disease
• Personal or family history of bleeding disorders
• Prior nasal surgery or trauma
• Nasal oxygen use or CPAP use 1

Patient Education and Prevention

1. Home care instructions:

   • Avoid nose picking, straining, heavy lifting (over 10 pounds), and bending over
   • Sleep with head slightly elevated
   • Avoid aspirin and ibuprofen unless medically necessary; acetaminophen is safe 1
   • Keep nasal mucosa moist with saline sprays and moisturizing agents

2. When to seek medical attention:

   • Return of bleeding from nose or mouth
   • Fever over 101°F
   • Increasing pain or swelling
   • Vision changes
   • Shortness of breath or labored breathing 1

Special Considerations for Elderly Patients

• Elderly patients are at higher risk for posterior epistaxis, which is more difficult to control 3
• Consider the impact of comorbidities (hypertension, cardiovascular disease)
• If the patient is on anticoagulants or antiplatelet medications that you haven't identified yet, do not discontinue these medications as first-line treatment 1
• Monitor blood pressure but do not aggressively lower it during acute bleeding, as this may cause end-organ damage 1

Follow-up Care

• Document the outcome of intervention within 30 days
• Consider referral to an otolaryngologist for:
  • Persistent or recurrent bleeding
  • Failed initial management attempts
  • Suspicion of underlying pathology requiring specialized evaluation 1

Remember that while nosebleeds are common and usually benign, in elderly patients they may be more severe and require more aggressive management. The key is to start with simple measures like compression before moving to more invasive interventions.