What is the best course of action for a 50 kg Indian male with prolonged epistaxis, petechiae, and normal coagulation studies?

Management of Epistaxis in a 50 kg Indian Male with Prolonged Bleeding

For a 50 kg Indian male with 5-day epistaxis, petechiae on nasal mucosa, and normal coagulation studies, the most effective first-line treatment is 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 tranexamic acid. 1

Initial Assessment and Management

1. Position and Compression:

   • Position the patient sitting upright with head slightly forward
   • Apply firm sustained compression to the lower third of the nose for 5-15 minutes 2, 1
   • This simple measure is effective in controlling many cases of epistaxis

2. Bleeding Site Identification:

   • Perform anterior rhinoscopy after removing any blood clots to identify the bleeding site 2
   • If bleeding source cannot be identified or is suspected to be posterior, perform nasal endoscopy 2, 1
   • The presence of petechiae on nasal mucosa suggests possible vascular fragility

3. Severity Assessment:

   • Evaluate for signs of significant blood loss (tachycardia, orthostatic hypotension, syncope)
   • Assess airway patency and hemodynamic stability
   • Consider the 3-day history with multiple episodes as potentially severe 2

Treatment Algorithm

First-Line Treatment:

1. Topical Tranexamic Acid:

   • Apply topical tranexamic acid to the bleeding site
   • Promotes hemostasis in 78% of patients versus 35% with oxymetazoline alone 1, 3
   • Can control bleeding within 10 minutes in 71% of patients compared to 31.2% with nasal packing 1
   • Tranexamic acid works by preventing clot breakdown (fibrinolysis) 4, 5

2. Nasal Cautery:

   • If bleeding site is clearly identified, perform nasal cautery after anesthetizing the area 2
   • Restrict cautery application only to the active or suspected site of bleeding 2
   • Electrocautery is more effective and has fewer recurrences (14.5% vs. 35.1%) than chemical cauterization 3

Second-Line Treatment (if bleeding persists):

1. Nasal Packing:
   • Apply if bleeding continues despite first-line measures 2
   • Options include:
     • 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) 3

Special Considerations

1. Investigation for Underlying Causes:

   • Despite normal coagulation studies, the presence of petechiae warrants further investigation
   • Consider additional tests:
     • Complete blood count with platelet count
     • Liver function tests
     • Assessment for platelet dysfunction
     • Consider referral to hematology if bleeding persists despite normal initial tests 1, 6

2. Management of Recurrent Bleeding:

   • Educate patient about proper nasal moisturization with saline gel or spray (1-3 times daily) 1
   • Recommend humidification and avoidance of digital trauma to the nose 1
   • If bleeding recurs despite treatment, consider referral to otolaryngology for endoscopic evaluation 1

3. Indications for Hospital Admission:

   • Posterior epistaxis
   • Bleeding not controlled with anterior packing
   • Significant hemodynamic instability
   • Need for blood transfusion 2, 1

Follow-up Care

• Schedule follow-up within 3-5 days to assess for recurrence
• Provide clear instructions on when to seek emergency care (bleeding lasting >30 minutes, large volume blood loss, signs of hypovolemia) 2
• Document risk factors that may increase frequency/severity of bleeding 1

The combination of compression, topical tranexamic acid, and appropriate nasal cautery offers the best approach for controlling epistaxis while minimizing complications in this patient with normal coagulation studies but concerning petechiae.