What are the treatment options for epistaxis?

Treatment of Epistaxis (Nosebleeds)

The first-line treatment for epistaxis is to have the patient sit with their head slightly forward while pinching the lower third of the nose continuously for 10-15 minutes. 1, 2

Initial Management

1. Patient positioning and compression:

   • Have the patient sit upright with head tilted slightly forward (to prevent blood from flowing down the throat)
   • Apply firm, sustained compression to the lower third (soft portion) of the nose for 10-15 minutes
   • Instruct patient to breathe through the mouth and spit out any blood 1, 2

2. Assessment after initial compression:

   • Remove blood clots and perform anterior rhinoscopy to identify the bleeding site 2
   • If bleeding persists after 15 minutes of continuous pressure, or if the patient becomes lightheaded, seek medical attention 1

Medical Management Options

If initial compression fails to control bleeding, the following interventions may be employed:

1. Topical vasoconstrictors:

   • Oxymetazoline nasal spray or cotton soaked in oxymetazoline/epinephrine can be applied 3

2. Cauterization:

   • For visible bleeding sites, apply chemical cautery (silver nitrate) or electrocautery
   • Electrocautery is more effective with fewer recurrences (14.5% vs 35.1%) compared to chemical cauterization 2, 4

3. Topical hemostatic agents:

   • Topical tranexamic acid (TXA) is highly effective, controlling bleeding within 10 minutes in 71% of patients (vs. 31.2% with nasal packing) 2, 5

4. Nasal packing:

   • If other methods fail, anterior nasal packing may be performed
   • Options include non-absorbable materials (petroleum jelly, BIPP gauze, PVA nasal tampons) or absorbable materials (Nasopore) 4
   • Newer hemostatic materials (Surgicel, Floseal, Spongostan) are more effective with fewer complications 4

Advanced Management (for persistent bleeding)

For cases requiring specialist intervention:

1. Nasal endoscopy:

   • Essential when the bleeding source is not anterior
   • Helps identify the bleeding site in most cases 2, 6

2. Surgical options:

   • Endoscopic arterial ligation (97% success rate)
   • Endovascular embolization (~80% success rate) 2, 4

Special Considerations

• Anticoagulant/antiplatelet medications: Patients on these medications should seek medical attention unless bleeding has stopped 1, 2
• Trauma-related epistaxis: Seek medical attention if there are signs of brain injury, nasal deformity, or facial fracture 1
• Posterior epistaxis: More likely to require hospitalization and nasal packing; often requires referral to otolaryngology 3

When to Seek Emergency Care

• Bleeding that persists beyond 15 minutes of continuous pressure
• Signs of hypovolemia or lightheadedness
• Epistaxis in patients taking anticoagulant/antiplatelet medications
• Trauma-associated epistaxis with signs of other injuries 1, 2

Patient Education

• Proper nasal moisturization techniques
• Home treatment methods (proper compression technique)
• Warning signs requiring medical attention 2

The evidence strongly supports a stepwise approach to epistaxis management, beginning with simple compression techniques that resolve most cases, followed by progressively more invasive interventions for persistent bleeding. The most recent guidelines emphasize the effectiveness of proper compression technique and the value of topical tranexamic acid as an effective treatment option.