What is the treatment for epistaxis?

Treatment of Epistaxis

The first-line treatment for epistaxis is to have the person sit with their head slightly forward while pinching the lower third or soft portion of the nose continuously for 10 to 15 minutes. 1

Initial Management

First Aid Approach

• Position the patient sitting upright with head tilted slightly forward (to prevent blood from entering airway or stomach)
• Apply firm, continuous pressure to the lower third (soft portion) of the nose for 10-15 minutes 1
• Instruct patient to breathe through the mouth and spit out any blood 1
• This simple compression technique alone resolves the vast majority of cases, including 20% of cases managed in emergency departments 1

Topical Treatments

• Oxymetazoline nasal spray can be used as an adjunct to compression therapy, as it shrinks swollen nasal membranes and helps control bleeding in 65-75% of cases 2, 3
• Topical tranexamic acid (TXA) is highly effective, controlling bleeding within 10 minutes in 71% of patients compared to only 31.2% with traditional nasal packing 4
• For visible bleeding sites, apply cotton soaked in oxymetazoline or epinephrine to help constrict blood vessels 5

When Initial Measures Fail

Cauterization

• If a specific bleeding site is identified through anterior rhinoscopy, nasal cautery can be performed after local anesthesia 6
• Silver nitrate is commonly used for chemical cautery 5
• Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 3

Nasal Packing

• If bleeding persists despite compression and topical treatments, nasal packing should be considered 6
• Options include:
  • Non-absorbable materials: petroleum jelly gauze, 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) 3

When to Seek Medical Attention

Patients should seek immediate medical attention if:

• Bleeding does not stop after 15 minutes of continuous pressure 1
• Patient becomes lightheaded from blood loss 1
• Epistaxis is due to trauma with signs of brain injury, nasal deformity, or facial fracture 1
• Patient is taking anticoagulant or antiplatelet medications, or has a blood-clotting disorder 1

Special Considerations

Anticoagulation Therapy

• For patients on anticoagulants, first-line treatments should be initiated prior to considering withdrawal of anticoagulation medications 6
• For patients on dual antiplatelet therapy with persistent bleeding, temporary discontinuation of one agent (preferably clopidogrel) may be considered in consultation with the prescribing physician 6

Severe or Recurrent Epistaxis

• For persistent/recurrent bleeding not controlled by packing or cauterization, consider referral for surgical options:
  • Endoscopic arterial ligation (97% success rate) 6
  • Endovascular embolization (~80% success rate, but higher risk of complications including stroke in 0.9-1.6% of cases) 6

Prevention of Recurrence

• For patients with recurrent epistaxis, recommend:
  • Nasal moisturization with saline gel or spray 1-3 times daily 6
  • Home humidification 6
  • Avoidance of digital trauma (nose picking) 6

Complications to Monitor

• Ongoing epistaxis can lead to anemia and hypovolemic shock due to blood loss 1
• Posterior nasal packing is associated with pain and risk of aspiration if dislodged 5

The evidence strongly supports that simple compression is effective for most cases of epistaxis, with topical agents like tranexamic acid and oxymetazoline providing significant additional benefit when needed. For persistent bleeding, a stepwise approach from cauterization to packing to surgical intervention is recommended.