How to manage epistaxis in an 80-year-old female?

Management of Epistaxis in an 80-Year-Old Female

Initial management of epistaxis in an elderly female should begin with firm sustained compression to the lower third of the nose for 10-15 minutes, followed by application of topical vasoconstrictors and cautery if a bleeding site is identified. 1

Initial Assessment and Management

1. First-line treatment:

   • Apply firm pressure to the lower third of the nose for 10-15 minutes 1
   • Apply oxymetazoline or other vasoconstrictors via nasal spray or cotton soaked in oxymetazoline/epinephrine 1:1,000 to control bleeding and improve visualization 1
   • Use topical anesthesia (lidocaine or tetracaine) to improve patient comfort 1

2. Visualization and cautery:

   • Perform anterior rhinoscopy after removing blood clots to identify the bleeding site 1
   • Use direct visualization with a headlight, nasal speculum, and suction 1
   • Apply cautery (preferably bipolar electrocautery) to the active bleeding site if visible 1
   • Avoid bilateral septal cautery to prevent septal perforation 1

3. If bleeding persists:

   • Consider topical tranexamic acid application, which has been shown to reduce bleeding time and rebleeding compared to anterior nasal packing 2
   • If necessary, proceed to anterior nasal packing 3

Special Considerations for Elderly Patients

1. Medication review:

   • Assess for anticoagulant or antiplatelet use (common in elderly patients)
   • For patients on antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent if on dual antiplatelet therapy (DAPT) 4
   • Reversal of anticoagulation should only be considered in life-threatening bleeding situations 1

2. Blood pressure management:

   • Control hypertension, which is often associated with posterior epistaxis in elderly patients 5
   • Consider diuretics or other antihypertensive medications if blood pressure is elevated 4

3. Comorbidity assessment:

   • Evaluate for conditions that may contribute to epistaxis in the elderly:
     • Hypertension
     • Atherosclerosis
     • Coagulation disorders
     • Chronic kidney or liver disease 4

Prevention of Recurrence

1. Patient education:

   • Avoid digital trauma (nose picking) and vigorous nose blowing 1
   • Regular nasal moisturization with saline gel or spray 1-3 times daily 1
   • Humidification in dry environments 1

2. Activity restrictions:

   • Avoid straining, lifting over 10 pounds, bending over, and exercising 4
   • Sleep with the head slightly elevated 4
   • Avoid over-the-counter pain medications that may increase bleeding (aspirin, ibuprofen) 4

When to Refer or Escalate Care

1. Indications for referral to otolaryngology or emergency department:

   • Posterior epistaxis (5-10% of cases) 1
   • Bleeding not controlled with anterior packing 1
   • Recurrent epistaxis despite treatment 1
   • Suspected underlying pathology requiring endoscopic evaluation 1

2. Warning signs requiring immediate attention:

   • Return of blood from nose or mouth
   • Fever over 101°F
   • Increasing pain
   • Vision changes
   • Shortness of breath or labored breathing
   • Loss of color around the skin of the nose
   • Swelling of the face
   • Diffuse skin rash 4

Potential Complications of Treatment

1. Nasal packing complications:

   • Risk of infection spreading to nose and sinuses
   • Decreased blood flow to areas of the nose
   • Septal perforations
   • Scar bands in the nasal cavity
   • Pressure sores of the external skin
   • Worsening of obstructive sleep apnea 4

2. Prevention of complications:

   • Consider oral antibiotics if risk for infection is high
   • Keep the nose and packing moist with nasal saline sprays
   • Ensure appropriate follow-up for packing removal 4

By following this algorithmic approach, epistaxis in elderly patients can be effectively managed while minimizing complications and preventing recurrence.