What is the treatment for epistaxis?

Treatment of Epistaxis

The first-line treatment for epistaxis is firm sustained compression to the lower third of the nose for 10-15 minutes, which should be attempted before proceeding to other interventions. 1

Initial Management Algorithm

1. First-line approach:

   • Apply firm pressure to the lower third of the nose for 10-15 minutes
   • Patient should be seated leaning forward to avoid blood flowing down the throat
   • Consider applying ice packs to the nasal bridge to promote vasoconstriction

2. If bleeding persists:

   • Apply vasoconstrictor spray such as oxymetazoline (Afrin) 2 to help constrict blood vessels, with a success rate of 65-75% 1, 3
   • Topical tranexamic acid may be particularly effective in patients on antiplatelet therapy 1 and has shown superior results compared to other topical agents in stopping bleeding within 10 minutes 4

Cauterization and Advanced Techniques

If the initial measures fail to control bleeding and a specific bleeding site can be identified:

• Cauterization is preferred over nasal packing 1
  • Electrocautery (especially bipolar) is more effective than chemical cautery with fewer recurrences (14.5% vs 35.1%) 1, 3
  • Should be performed under local anesthesia
  • Caution: Avoid excessive or extensive cautery to prevent septal damage

Nasal Packing

For bleeding that cannot be controlled by compression, vasoconstrictors, or cauterization:

• Options include:

  • Non-absorbable materials (petroleum jelly, BIPP gauze, PVA nasal tampons)
  • Absorbable materials (Nasopore)
  • Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) 1, 3

• Important considerations:

  • Monitor for complications including infection, decreased blood flow, septal perforations, pressure sores, and worsening of obstructive sleep apnea 1
  • Patients with anterior nasal packing may be discharged with appropriate antibiotics and follow-up
  • Posterior packing typically requires hospital admission for monitoring

Management of Persistent or Severe Bleeding

For intractable cases not responding to the above measures:

• Endoscopic arterial ligation targeting the sphenopalatine artery (SPA) has a 97% success rate compared to 62% with conventional nasal packing 1, 3
• Embolization may be considered with approximately 80% success rate but carries higher risk of serious complications including stroke (0.9-1.6%) 1

Special Considerations for Patients on Anticoagulants/Antiplatelets

• For patients on dual antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with the prescribing physician 1
• Resumption of antiplatelet therapy should occur as soon as bleeding is controlled 1
• Topical tranexamic acid has shown particular benefit in these patients 1, 5

Post-Treatment Care and Prevention

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

When to Refer to Specialist or Emergency Department

• Posterior epistaxis
• Bleeding not controlled with anterior packing
• Recurrent epistaxis despite treatment
• Suspected underlying pathology requiring endoscopic evaluation 1

Warning Signs Requiring Immediate Attention

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath
• Loss of color around the skin of the nose
• Swelling of the face
• Diffuse skin rash 1

Important note: Recent research suggests that topical tranexamic acid at a dose of 1000 mg may be more effective than 500 mg, with decreased rates of recurrent bleeding and low incidence of side effects 6. This represents a promising advancement in epistaxis management that could be incorporated into treatment protocols.