What is the treatment for a persistent epistaxis (nosebleed) that won't stop?

Treatment for Persistent Epistaxis (Nosebleed)

For persistent nosebleeds that won't stop, apply firm sustained compression to the lower third of the nose for 10-15 minutes, followed by topical vasoconstrictors such as oxymetazoline spray, and if bleeding continues, seek medical attention for nasal cautery or packing. 1

Step-by-Step Management Algorithm

First-Line Measures (Home Treatment)

1. Proper Compression Technique

   • Lean forward to prevent blood from flowing down the throat
   • Apply firm pressure to the lower third (soft part) of the nose for 10-15 minutes continuously 1
   • This technique alone has a high success rate when performed correctly

2. Topical Vasoconstrictors

   • If bleeding continues, blow nose to clear clots
   • Apply oxymetazoline or phenylephrine nasal spray (2 sprays in bleeding nostril)
   • Continue compression for another 5 minutes
   • May repeat once if needed 2
   • Success rate: 65-75% 1, 3

3. Topical Hemostatic Agents

   • Tranexamic acid may be effective, especially for patients on antiplatelet therapy 1
   • Promotes hemostasis in approximately 78% of patients (vs. 35% with oxymetazoline alone) 3

When to Seek Medical Attention

Seek immediate medical care if:

• Bleeding persists despite the above measures
• Bleeding is severe or you feel weak/lightheaded
• Blood is flowing down the throat (posterior bleeding)
• You're on anticoagulation/antiplatelet medications 2, 1

Medical Interventions

1. Nasal Cauterization

   • Preferred when a specific bleeding site can be identified
   • Performed under local anesthesia
   • Electrocautery (especially bipolar) is more effective than chemical cautery
   • Lower recurrence rate (14.5% vs. 35.1%) compared to chemical cauterization 1, 3

2. Nasal Packing Options

   • Non-absorbable materials: Petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel)
   • Absorbable materials: Nasal tampon (Nasopore)
   • Newer hemostatic materials: Hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) 1, 3
   • For patients on anticoagulants or with bleeding disorders, resorbable packing is preferred 2

3. For Persistent/Severe Bleeding

   • Endoscopic arterial ligation (primarily sphenopalatine artery)
     • Success rate: 97% (vs. 62% with conventional packing) 1, 3
   • Embolization for intractable cases
     • Success rate: approximately 80%
     • Higher risk of serious complications including stroke (0.9-1.6%) 1

Special Considerations

Patients on Anticoagulants/Antiplatelets

• In the absence of life-threatening bleeding, initiate first-line treatments before considering reversal or withdrawal of medications 2
• For patients on dual antiplatelet therapy with persistent bleeding, temporary discontinuation of one agent (preferably clopidogrel) may be considered in consultation with the prescribing physician 1
• Resume antiplatelet therapy as soon as bleeding is controlled 1

Prevention of Recurrence

• Nasal moisturization with saline gel or spray 1-3 times daily
• Humidification in dry environments
• Avoid digital trauma (nose picking) and vigorous nose blowing 2, 1
• After cauterization, avoid nose blowing, strenuous activity, heavy lifting, or placing cotton/tissues in the nose for at least a week 2

Common Pitfalls and Caveats

1. Incorrect Compression Technique

   • Many healthcare providers (70%) don't know the correct site for nasal compression 4
   • Compression should be on the lower third of the nose, not the bony upper portion

2. Incorrect Head Position

   • Tilting head backward increases risk of blood aspiration
   • Proper position is leaning forward 4

3. Inadequate Duration of Compression

   • Many patients release pressure too soon
   • Full 10-15 minutes of continuous pressure is necessary 1

4. Overlooking Underlying Causes

   • Recurrent epistaxis may indicate systemic disease or hereditary hemorrhagic telangiectasia 5
   • Consider evaluation for hypertension, coagulation disorders, or chronic kidney/liver disease 1

5. Excessive Cauterization

   • Can lead to septal damage or perforation
   • Should be limited to the specific bleeding site 1

By following this algorithm, most persistent nosebleeds can be effectively controlled, reducing the need for more invasive interventions and improving patient outcomes.