What is the treatment for epistaxis (nose bleeds)?

Treatment for Nose Bleeds (Epistaxis)

The first-line treatment for epistaxis is applying firm sustained compression to the lower third of the nose for 10-15 minutes, which has a high success rate when performed correctly. 1

Initial Management Algorithm

1. First-line approach:

   • Apply firm sustained compression to the lower third of the nose for 10-15 minutes 1
   • Patient should be seated leaning slightly forward to avoid blood flowing into the throat
   • Apply ice packs to the nasal bridge to promote vasoconstriction 2

2. If bleeding persists:

   • Apply topical vasoconstrictors such as oxymetazoline or phenylephrine, which have a 65-75% success rate 1, 3
   • These are available over-the-counter but should be used with caution in patients with hypertension 1

3. For persistent bleeding:

   • Consider topical tranexamic acid (TXA) application via cotton pledgets soaked with TXA solution, particularly effective for patients on antiplatelet medications 1
   • TXA promotes hemostasis in approximately 78% of patients, compared to 35% with oxymetazoline 3

Advanced Management Options

If initial measures fail to control bleeding:

1. Cauterization:

   • Perform electrocautery or chemical cauterization (e.g., silver nitrate) under local anesthesia if a specific bleeding site is identified 1, 2
   • Electrocautery is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization 3
   • Use cauterization with caution to avoid septal damage 1

2. Nasal packing options:

   • Non-absorbable materials: petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino) 3
   • Absorbable materials: nasal tampon (Nasopore) 3
   • Newer hemostatic materials: hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan), fibrin glue 3
   • Be aware of packing complications: infection risk, decreased blood flow, septal perforations, worsening of obstructive sleep apnea 1

3. Surgical interventions for intractable cases:

   • Endoscopic arterial ligation targeting the sphenopalatine artery (SPA) - 97% success rate compared to 62% with conventional nasal packing 1, 3
   • Embolization for truly intractable cases - approximately 80% success rate but carries risk of serious complications including stroke (0.9-1.6%) 1, 3

Special Considerations

For anticoagulated patients:

• Saline gel has shown excellent results in preventing recurrent epistaxis 1
• Consider temporary discontinuation of one antiplatelet agent (preferably clopidogrel) in consultation with the prescribing physician for patients on dual antiplatelet therapy with persistent bleeding 1
• Resume antiplatelet therapy as soon as bleeding is controlled 1

Contraindications and precautions:

• Use TXA with caution in patients with renal dysfunction due to risk of neurotoxicity and ocular toxicity 1
• Avoid TXA in patients with cirrhosis 1
• Limit use of vasoconstrictors to 3-5 days to prevent rebound congestion and rhinitis medicamentosa 1

Prevention of Recurrence

• Recommend nasal moisturization with saline gel or spray 1-3 times daily 1
• Advise humidification in dry environments 1
• Educate patients to avoid digital trauma (nose picking) and vigorous nose blowing 1

When to Refer to Specialist

Refer patients 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 or labored breathing
• Loss of color around the skin of the nose
• Swelling of the face
• Diffuse skin rash 1