What is the treatment for epistaxis?

Treatment of Epistaxis (Nosebleed)

For epistaxis treatment, first instruct patients to sit with head slightly forward, pinch the lower third of the nose for 10-15 minutes, and breathe through the mouth while spitting out any blood. 1

First-Line Management

1. Initial measures:

   • Position: Patient sitting upright with head tilted slightly forward
   • Apply direct pressure: Pinch the soft part of the nose (lower third) for 10-15 minutes continuously
   • Breathe through mouth and spit out any blood 1

2. Pharmacological options:

   • Topical vasoconstrictors:
     • Oxymetazoline or xylometazoline nasal sprays are preferred first-line agents 1, 2
     • These control 65-75% of nosebleeds in emergency settings 3
   • Topical tranexamic acid (TXA):
     • Highly effective, controlling bleeding within 10 minutes in 71% of patients (vs 31.2% with nasal packing) 1, 4
     • Promotes hemostasis in 78% of patients (vs 35% with oxymetazoline) 3

Second-Line Management

If bleeding persists despite first-line measures:

1. Nasal examination:

   • Perform anterior rhinoscopy after removing blood clots
   • If bleeding site cannot be identified or is suspected to be posterior, perform nasal endoscopy 1

2. Cauterization:

   • Apply after anesthetizing the area if bleeding site is clearly identified
   • Restrict application only to the active/suspected bleeding site
   • Electrocautery is more effective than chemical cauterization (14.5% vs 35.1% recurrence) 1, 3

3. Nasal packing options:

   • Non-absorbable materials: petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel), Foley catheter, balloons (Rapid-Rhino) 1, 3
   • Absorbable materials: nasal tampon (Nasopore) 3
   • Newer hemostatic materials: hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan), fibrin glue 3

Important: The American Academy of Otolaryngology-Head and Neck Surgery recommends against using adrenaline (epinephrine) nose packing due to cardiovascular risks, patient discomfort, and availability of safer alternatives 1

Management of Refractory Epistaxis

For persistent/recurrent bleeding not controlled by packing or cauterization:

1. Surgical options:

   • Endoscopic arterial ligation (97% success rate)
   • Endovascular embolization (~80% success rate, but higher risk of serious complications including 0.9-1.6% stroke risk) 1

2. Special considerations for anticoagulated patients:

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

Indications for Hospital Admission

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

Patient Education and Follow-Up

• Provide education on proper nasal moisturization techniques and home treatment methods
• Schedule follow-up within 3-5 days to assess for recurrence
• Provide clear instructions on when to seek emergency care (bleeding lasting >30 minutes or signs of hypovolemia) 1

Special Considerations

• Patients taking anticoagulant/antiplatelet medications or with blood-clotting disorders should seek medical attention promptly 1
• Tranexamic acid significantly reduces risk of rebleeding within 10 days (from 67% to 47%) 5
• Patient satisfaction is significantly higher with topical tranexamic acid compared to anterior nasal packing (8.5/10 vs 4.4/10) 4