What can a primary care doctor do for a nose bleed (epistaxis)?

Management of Epistaxis in Primary Care

Primary care physicians should treat active nosebleeds with firm sustained compression to the lower third of the nose for 5-15 minutes, followed by identification of the bleeding site and appropriate intervention with topical vasoconstrictors, nasal cautery, or nasal packing based on severity and response to initial measures. 1, 2

Initial Assessment and Management

Severity Assessment

• At initial contact, distinguish patients requiring prompt management from those who don't 1
• Indicators of severe bleeding requiring emergency referral:
  • Bleeding duration >30 minutes
  • Signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension)
  • Bleeding from both sides of nose or into mouth
  • History of hospitalization or blood transfusion for nosebleeds

  • 3 recent episodes of nasal bleeding 1

First-Line Treatment

1. Position patient leaning forward (to prevent blood aspiration) 2, 3
2. Apply firm sustained compression to the lower third of the nose for 5-15 minutes 1, 4
3. Apply ice packs to the nasal bridge to promote vasoconstriction 2

Bleeding Site Identification and Targeted Treatment

Anterior Rhinoscopy

• Remove any blood clots to identify the bleeding site 1
• 90% of nosebleeds originate from the anterior nasal circulation and can be managed in outpatient settings 5

Treatment Options Based on Identified Bleeding Site:

1. Topical vasoconstrictors:

   • Oxymetazoline nasal spray stops 65-75% of nosebleeds 6, 5
   • Apply cotton soaked in oxymetazoline or epinephrine as adjunct to compression 5

2. Nasal cautery:

   • For localized continued bleeding or prominent vessels
   • Anesthetize the site before cautery
   • Restrict application only to active/suspected bleeding site 1
   • Silver nitrate cautery is more effective than chemical cauterization (14.5% vs 35.1% recurrence) 6

3. Topical hemostatic agents:

   • Tranexamic acid promotes hemostasis in 78% of patients vs 35% with oxymetazoline alone 2, 6
   • Controls bleeding within 10 minutes in 71% of patients vs 31.2% with nasal packing 2

4. Nasal packing:

   • For persistent bleeding not controlled by above measures
   • Use resorbable packing for patients with suspected bleeding disorders or on anticoagulants 1
   • Options include:
     • Non-absorbable: petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel)
     • Absorbable: nasal tampon (Nasopore)
     • Newer hemostatic materials: hemostatic gauzes (Surgicel), thrombin matrix (Floseal) 6

Patient Education and Prevention

• Educate patients about:
  • Proper nasal moisturization with saline gel/spray 1-3 times daily 2
  • Home treatment techniques for future episodes
  • Avoiding digital trauma to the nose
  • Using humidification 1, 2
  • Indications to seek additional medical care 1

When to Refer

• Refer to otolaryngology or emergency department for:
  • Posterior epistaxis (more likely to require hospitalization)
  • Bleeding not controlled with anterior packing
  • Recurrent epistaxis despite treatment
  • Suspected underlying pathology requiring endoscopic evaluation 2, 5
  • Persistent or recurrent bleeding for consideration of surgical arterial ligation or endovascular embolization 1

Special Considerations

• Document risk factors that increase frequency/severity of bleeding:

  • Personal/family history of bleeding disorders
  • Use of anticoagulant/antiplatelet medications
  • Intranasal drug use 1
  • Hypertension
  • Chronic alcohol use 2

• For patients on anticoagulants/antiplatelets:

  • In absence of life-threatening bleeding, initiate first-line treatments before considering medication changes 1
  • For persistent bleeding on dual antiplatelet therapy, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with prescribing physician 2

Common Pitfalls to Avoid

• Incorrect compression technique: 30% of healthcare providers don't know the correct site for nasal compression 3
• Incorrect head positioning: Tilting head backward increases risk of aspiration 3
• Failure to identify bleeding site before treatment
• Overuse of nasal packing when simpler measures might suffice
• Not providing adequate patient education about prevention and home management