What is the treatment for epistaxis (nosebleed)?

Treatment of Epistaxis (Nosebleed)

The first-line treatment for epistaxis is firm sustained compression to the lower third (soft portion) of the nose for at least 5-15 minutes while sitting upright with the head tilted slightly forward. 1

Initial Assessment and Management

Determining Severity

• Distinguish patients requiring prompt management from those who don't:
  • Severe: bleeding duration >30 minutes, history of hospitalization for nosebleeds, prior blood transfusion, or >3 recent episodes 1
  • Concerning signs: bilateral bleeding, blood from mouth, tachycardia, syncope, or orthostatic hypotension 1
  • Comorbidities increasing risk: hypertension, cardiopulmonary disease, anemia, bleeding disorders, liver/kidney disease 1

First-Line Treatment Steps

1. Position the patient sitting upright with head tilted slightly forward (prevents blood from entering airway or stomach) 2
2. Apply firm sustained compression to the lower third (soft part) of the nose for 5-15 minutes 1, 2
3. Instruct patient to breathe through the mouth and spit out any blood 2
4. If bleeding continues, blow nose to clear clots and apply topical vasoconstrictors:
   • Oxymetazoline or phenylephrine nasal spray (2 sprays in bleeding nostril) 1, 3
   • Success rate: 65-75% of cases resolve with vasoconstrictor application 2, 3

Second-Line Interventions

For Identified Bleeding Site

1. Anesthetize the bleeding site with topical lidocaine or tetracaine 2
2. Apply cautery only to the active bleeding site:
   • Electrocautery is more effective than chemical cautery (14.5% vs 35.1% recurrence) 2, 3
   • Avoid bilateral septal cautery to prevent septal perforation 2

For Persistent Bleeding

1. Nasal packing if bleeding precludes identification of site despite compression 1
2. Use resorbable packing for patients with suspected bleeding disorders or those on anticoagulation/antiplatelet medications 1
3. Consider topical tranexamic acid for patients on antiplatelet medications 2
   • Promotes hemostasis in 78% of patients (vs 35% with oxymetazoline and 31% with nasal packing) 3

Special Considerations

Anticoagulation Management

• In the absence of life-threatening bleeding, initiate first-line treatments prior to:
  • Transfusion
  • Reversal of anticoagulation
  • Withdrawal of anticoagulation/antiplatelet medications 1
• Patients should consult with the clinician who prescribed their blood-thinning medication 1

Recurrent or Difficult-to-Control Epistaxis

• Perform anterior rhinoscopy to identify bleeding source after removing blood clots 1
• Consider nasal endoscopy to identify bleeding sites (87-93% success rate) 2
• Evaluate for surgical arterial ligation or endovascular embolization for persistent/recurrent bleeding not controlled by packing or cauterization 1
• Assess for nasal telangiectasias in patients with recurrent bilateral nosebleeds (possible hereditary hemorrhagic telangiectasia) 2

Prevention of Recurrence

• Educate patients about preventive measures:
  • Avoid digital trauma (nose picking) and vigorous nose blowing 1
  • Apply moisturizing/lubricating agents (saline gel, petroleum jelly) to the anterior nasal septum 1, 2
  • Use humidification at bedside 1
  • Apply saline nasal sprays to keep nasal mucosa moist 2

When to Seek Medical Attention

• Bleeding continues after 15 minutes of continuous pressure 2
• Patient becomes lightheaded from blood loss 2
• Nosebleed is associated with trauma 2
• Patient is taking anticoagulant or antiplatelet medications 2
• Patient has a known bleeding disorder 2

Common Pitfalls to Avoid

1. Incorrect compression technique - only 30% of healthcare providers correctly identify the site for nasal compression 4
2. Improper head positioning - tilting head backward can cause blood to enter the airway or stomach 2
3. Insufficient compression time - compression should be maintained for at least 5-15 minutes 1, 2
4. Bilateral septal cautery - increases risk of septal perforation 2
5. Premature discontinuation of anticoagulants without consulting prescribing physician 1

Most nosebleeds (90-95%) are anterior in origin and benign, responding well to the simple first-line measures outlined above 2, 5. However, posterior epistaxis (5-10% of cases) is more serious, often requiring hospitalization and specialized treatment 2.