What is the first-line treatment for epistaxis (nose bleed)?

First-Line Treatment for Epistaxis (Nosebleed)

The first-line treatment for epistaxis is firm sustained compression to the lower third of the nose for 10-15 minutes, with the patient sitting upright and the head tilted slightly forward. 1, 2

Initial Management Algorithm

1. Patient Positioning and Direct Pressure:

   • Have the patient sit upright with head tilted slightly forward (to prevent blood from draining down the throat)
   • Apply firm, continuous pressure by pinching the soft part (lower third) of the nose for 10-15 minutes without releasing 1
   • This simple technique resolves the majority of nosebleeds, including 20% of cases managed in emergency departments 1

2. Topical Vasoconstrictors (if bleeding persists):

   • Apply over-the-counter nasal decongestant sprays containing oxymetazoline or phenylephrine
   • These can help stop bleeding in 65-75% of cases 1, 3
   • Application technique: Clear any clots first, then apply 2 sprays to the bleeding nostril and continue compression for 5 minutes 2

3. Site Identification and Targeted Treatment:

   • Perform anterior rhinoscopy after removing blood clots to identify the bleeding site 1
   • 90-95% of nosebleeds originate from the anterior nasal cavity 1
   • For identified bleeding sites, apply appropriate intervention: topical vasoconstrictors, nasal cautery, or moisturizing/lubricating agents 2

Special Considerations

For Patients on Anticoagulants:

• Do not discontinue anticoagulation medications before attempting first-line treatments 1
• Use resorbable packing materials if packing becomes necessary 2
• Consider topical tranexamic acid for patients on antiplatelet medications 1

When to Seek Medical Attention:

• If bleeding doesn't stop after 15 minutes of proper compression
• If bleeding is severe or recurrent
• If the patient feels lightheaded or weak
• If the patient is on anticoagulants 1

Prevention of Recurrence

• Nasal moisturization with saline gel or spray 1-3 times daily 1
• Avoid digital trauma (nose picking) and vigorous nose blowing 2
• Consider bedside humidification, especially during sleep 1
• For CPAP users: add humidification to the circuit and optimize pressure settings 1

Common Pitfalls to Avoid

1. Incorrect head positioning: Many healthcare providers incorrectly instruct patients to tilt their head backward, which can lead to blood aspiration. The correct position is head tilted slightly forward 4

2. Improper compression technique: Compression should be applied to the lower third (soft part) of the nose, not the bony upper portion. A study found that only 30% of healthcare providers correctly identified the proper compression site 4

3. Releasing pressure too early: Compression should be maintained continuously for at least 10-15 minutes without checking if the bleeding has stopped 1

4. Premature discontinuation of anticoagulants: In non-life-threatening epistaxis, standard first-line treatments should be attempted before considering changes to anticoagulation therapy 1

For persistent or severe epistaxis despite these measures, referral to otolaryngology for more advanced interventions such as nasal packing, cauterization, or endoscopic evaluation may be necessary 1.