What are the management options for epistaxis (nosebleed)?

Management of Epistaxis (Nosebleeds)

For epistaxis, the patient should sit with their head slightly forward with their nostrils pinched for 10-15 minutes as first-line management. 1, 2

Initial Assessment and Management

First-Line Measures:

• Position patient sitting upright with head tilted slightly forward (prevents blood from entering airway or stomach)
• Apply firm, sustained compression to the lower third (soft portion) of the nose for 10-15 minutes 1, 2
• Instruct patient to breathe through mouth and spit out any blood 1, 2
• Remove any blood clots and perform anterior rhinoscopy to identify bleeding site 2

When to Seek Medical Attention:

• Bleeding that doesn't stop after 15 minutes of continuous pressure 1
• Patient becomes lightheaded from blood loss 1
• Epistaxis due to trauma with signs of brain injury, nasal deformity, or facial fracture 1
• Patients taking anticoagulant/antiplatelet medications or with blood-clotting disorders 1, 2

Advanced Management Options (Medical Setting)

Topical Treatments:

• Topical vasoconstrictors (e.g., oxymetazoline) can stop 65-75% of nosebleeds 3
• Topical tranexamic acid promotes hemostasis in up to 78% of patients (significantly better than oxymetazoline at 35%) 2, 3

Cauterization:

• After anesthetizing the area, apply cautery if bleeding site is clearly identified 2
• Options include:
  • Chemical cautery
  • Electrocautery (more effective with fewer recurrences - 14.5% vs 35.1%) 3

Nasal Packing:

• Used when bleeding continues despite first-line measures 2
• Non-absorbable materials: petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino) 2, 3
• Absorbable materials: nasal tampon (Nasopore) 3
• Newer hemostatic materials: hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan), fibrin glue 3

Surgical Interventions (for Refractory Cases):

• Endoscopic arterial ligation, primarily targeting the sphenopalatine artery (97% success rate) 2, 3
• Endoscopic cauterization (more effective than ligation) 3
• Arterial embolization for intractable cases (~80% success rate) but with higher risk of serious complications including stroke (0.9-1.6%) 2

Special Considerations

Risk Factors to Document:

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

Prevention of Recurrence:

• Nasal moisturization with saline gel or spray (1-3 times daily)
• Humidification
• Avoidance of digital trauma to the nose 2

Clinical Pearls and Pitfalls

• Pitfall: Leaning head backward can cause blood to flow into the throat, leading to aspiration or vomiting
• Pitfall: Failure to apply adequate pressure for sufficient time (minimum 10 minutes)
• Pitfall: Missing posterior bleeds, which are often more severe and difficult to control
• Pearl: Cryotherapy (ice) application has insufficient evidence to recommend its use 1
• Pearl: For patients on dual antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with prescribing physician 2

The management approach should follow a stepwise algorithm from simple compression to more invasive interventions based on bleeding severity, with hospital admission considered for patients with significant comorbidities, posterior epistaxis, or complications of blood loss 2, 4.