Initial Management of Epistaxis in an Outpatient Setting
The initial management for epistaxis (nosebleed) in an outpatient setting should begin with firm sustained compression to the lower third of the nose for 10-15 minutes as the first-line treatment. 1
Step-by-Step Management Algorithm
1. First-Line Management
- Compression Technique:
- Apply firm pressure to the lower third (soft part) of the nose
- Maintain pressure continuously for 10-15 minutes
- Patient should be seated leaning forward to prevent blood from flowing down the throat
- Apply ice pack to the bridge of the nose (can help with vasoconstriction)
2. Assessment After Initial Compression
- If bleeding stops: Provide prevention education
- If bleeding continues: Proceed to examination and further interventions
3. Examination and Identification of Bleeding Site
- Use proper equipment:
- Adequate lighting (headlamp preferred)
- Nasal speculum
- Suction to clear blood clots 1
- Perform anterior rhinoscopy to identify bleeding site (90-95% of cases are anterior) 1
- Remove blood clots to improve visualization
4. Topical Vasoconstriction
- Apply oxymetazoline or other vasoconstrictors:
- This helps control bleeding and improves visualization of the bleeding site
5. Cautery (If Bleeding Site Identified)
- Apply topical anesthesia (lidocaine or tetracaine) 2, 1
- Restrict cautery application only to the active bleeding site 2
- Preferred method: Electrocautery (bipolar when available) is more effective than chemical cautery 1
- Alternative: Silver nitrate chemical cautery if electrocautery not available
- Avoid bilateral septal cautery to prevent septal perforation 1
6. Nasal Packing (If Cautery Fails or Bleeding Site Not Identified)
- Consider resorbable materials for patients with bleeding disorders or on anticoagulants 1
- Non-absorbable options include petroleum jelly gauze, BIPP gauze, or commercial nasal tampons (e.g., Merocel) 4
- Newer hemostatic materials (e.g., Surgicel, Floseal) may be more effective with fewer complications 4
7. Tranexamic Acid Consideration
- Topical tranexamic acid (TXA) application can be an effective alternative to nasal packing
- Studies show TXA stops bleeding faster (within 10 minutes in most cases) and has fewer rebleeds compared to anterior nasal packing 5
Special Considerations
Anticoagulation
- Patients on anticoagulants should seek medical care if bleeding doesn't stop promptly 1
- Reversal of anticoagulation should only be considered in life-threatening bleeding 1
Posterior Epistaxis
- More common in elderly patients
- Often associated with hypertension and anticoagulant use 6
- More likely to require hospitalization and nasal packing 3
- Consider referral to otolaryngology or emergency department 1
Referral Indications
- Posterior epistaxis
- Bleeding not controlled with anterior packing
- Recurrent epistaxis despite treatment
- Suspected underlying pathology requiring endoscopic evaluation 1
Prevention Education
- Avoid digital trauma (nose picking) and vigorous nose blowing
- Regular nasal moisturization with saline gel or spray 1-3 times daily
- Consider humidification in dry environments 1
Common Pitfalls to Avoid
- Insufficient duration of compression (must be at least 10-15 minutes continuously)
- Improper compression technique (not applying pressure to the soft part of the nose)
- Bilateral septal cautery (increases risk of septal perforation)
- Excessive or repeated use of vasoconstrictors (can cause rhinitis medicamentosa) 2
- Overlooking posterior bleeding sources in persistent cases
- Failing to provide prevention education to reduce recurrence
By following this structured approach, most anterior epistaxis cases can be effectively managed in the outpatient setting, reducing the need for emergency department visits and hospitalization.