What is the best next step for a patient with a nosebleed (epistaxis) lasting 30 minutes with an identified bleeding side after applying continuous pressure?

Management of Identified Bleeding Site in Epistaxis After 30 Minutes

For a patient with a nosebleed lasting 30 minutes with an identified bleeding site, nasal cautery should be performed after anesthetizing the area, as this is more effective and has fewer recurrences (14.5% vs. 35.1%) than other treatments. 1, 2

Assessment and Initial Management

When a patient presents with epistaxis lasting 30 minutes:

1. Confirm proper compression technique was applied:

   • Firm sustained compression to the lower third of the nose for at least 5 minutes 3
   • Patient should be sitting upright with head tilted slightly forward 1

2. Assess severity indicators:

   • Bleeding duration >30 minutes is considered severe according to UK epistaxis audit 3
   • Check for signs of hypovolemia (tachycardia, syncope, orthostatic hypotension) 3, 1
   • Evaluate for bleeding from both sides of nose or into mouth 3

Treatment Algorithm for Identified Bleeding Site

Step 1: Prepare for Cautery

• Clean the nasal cavity to remove blood clots and improve visualization 1
• Apply topical anesthetic with vasoconstrictor (e.g., lidocaine with epinephrine) 1

Step 2: Perform Cautery

• Apply cautery (preferably electrocautery) only to the identified bleeding site 1, 2
• Electrocautery is superior to chemical cauterization with fewer recurrences (14.5% vs 35.1%) 2

Step 3: If Cautery Fails

• Apply topical tranexamic acid which promotes hemostasis in 78% of patients (vs. 35% with oxymetazoline) 1, 2
• If bleeding persists, proceed to nasal packing:
  • Non-absorbable materials (e.g., Merocel, Rapid-Rhino)
  • Absorbable materials (e.g., Nasopore)
  • Newer hemostatic materials (e.g., Surgicel, Floseal) which are more effective with fewer complications 1, 2

Special Considerations

• Location matters: Anterior bleeding (most common) is generally easier to control than posterior bleeding 4

• Risk factors to assess:

  • Use of anticoagulants/antiplatelet medications
  • Hypertension (especially in elderly patients)
  • Bleeding disorders
  • Liver or kidney disease 3, 1

• Indications for referral to emergency department:

  • Failure to control bleeding with cautery and packing
  • Signs of significant blood loss
  • Posterior bleeding source 1

Follow-up Care

• Schedule follow-up within 3-5 days to assess for recurrence 1
• Recommend nasal moisturization with saline gel or spray 1-3 times daily to prevent recurrence 1
• Educate patient about proper nasal care, including humidification and avoiding digital trauma 1

Common Pitfalls to Avoid

• Pitfall #1: Failing to properly identify the bleeding site before cautery

  • Solution: Ensure adequate visualization with proper positioning, lighting, and suction 1, 4

• Pitfall #2: Excessive or bilateral cautery

  • Solution: Apply cautery only to the active bleeding site to avoid septal perforation 1

• Pitfall #3: Dismissing patients too quickly after apparent control

  • Solution: Observe for at least 15-30 minutes after bleeding stops to ensure stability 1