What are the management options for epistaxis (nosebleed)?

Management of Epistaxis (Nosebleed)

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 more invasive interventions. 1

Initial Management

1. First-line measures:

   • Apply firm pressure to the lower third of the nose for 10-15 minutes
   • Consider vasoconstrictor spray (e.g., oxymetazoline/Afrin) with success rates of 65-75% 1
   • Apply ice packs to help constrict blood vessels
   • Topical tranexamic acid is particularly effective for patients on antiplatelet therapy 1, 2

   Recent research shows topical tranexamic acid reduces bleeding time and has fewer rebleeds compared to anterior nasal packing 2

2. If bleeding persists - Cauterization:

   • Preferred over nasal packing when a specific bleeding site can be identified
   • 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 Options

If bleeding continues despite initial measures:

1. Non-absorbable materials:

   • Petroleum jelly gauze
   • PVA nasal tampons (Merocel)
   • Foley catheter
   • Balloon systems (Rapid-Rhino)

2. Absorbable materials:

   • Nasal tampon (Nasopore)

3. Newer hemostatic materials (more effective with fewer complications):

   • Hemostatic gauzes (Surgicel)
   • Thrombin matrix (Floseal)
   • Gelatin sponge (Spongostan)
   • Fibrin glue

Note: Nasal packing carries risks including infection, decreased blood flow to nasal areas, septal perforations, scar bands, pressure sores, and worsening of obstructive sleep apnea 1

Management of Persistent/Severe Bleeding

For refractory cases:

1. Endoscopic arterial ligation:

   • Primarily targeting the sphenopalatine artery (SPA)
   • Success rate of 97% compared to 62% with conventional nasal packing 1, 3

2. Embolization:

   • Reserved for intractable cases
   • Success rate of approximately 80%
   • Higher risk of serious complications including stroke (0.9-1.6%) 1

Post-Treatment Care

• 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

Special Considerations

Antiplatelet/Anticoagulant Therapy

• For patients on dual antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with the prescribing physician 1
• Resume antiplatelet therapy as soon as bleeding is controlled

Anterior vs. Posterior Epistaxis

• Anterior epistaxis (most common): Usually more easily managed with compression, cautery, or anterior packing
• Posterior epistaxis (more severe): May require posterior packing, hospitalization, and specialized interventions 1

When to Refer/Emergency Care

Refer to otolaryngology or emergency department for:

• 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
• Facial swelling
• Diffuse skin rash 1

Diagnostic Evaluation for Recurrent Epistaxis

• Nasal endoscopy is the best imaging modality for chronic recurrent epistaxis (identifies bleeding site in 87-93% of cases) 1
• Evaluate for contributing conditions:
  • Hypertension
  • Atherosclerosis
  • Coagulation disorders
  • Chronic kidney or liver disease 1