What is the next step in management for a patient with an identified source of epistaxis (nosebleed)?

Management of Identified Nosebleed Source

For a patient with an identified source of epistaxis, the next step in management should be to apply appropriate cautery (chemical or electrical) to the bleeding site if clearly visualized, or to apply targeted nasal packing if cautery is not appropriate. 1

Assessment and Initial Management Algorithm

1. When bleeding site is identified through anterior rhinoscopy:

   • First-line treatment: Apply chemical cautery (silver nitrate) or electrocautery directly to the bleeding site 1
   • Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 2

2. If cautery is not appropriate (based on location or severity):

   • Apply targeted nasal packing to the specific bleeding site
   • Consider topical tranexamic acid which promotes hemostasis in 78% of patients (versus 35% for oxymetazoline and 31% for standard nasal packing) 2

3. For packing selection:

   • Anterior bleeding: Use resorbable materials (e.g., Nasopore) or non-absorbable materials (e.g., petroleum jelly, BIPP gauze, Merocel) 2
   • Posterior or severe bleeding: Consider specialized packing (e.g., Rapid-Rhino balloon) or newer hemostatic materials (e.g., Surgicel, Floseal, Spongostan) 2

Patient Education After Intervention

After applying cautery or packing, patient education is essential:

• Explain the type of packing placed and removal plan if non-resorbable 3
• Instruct on post-procedure care including:
  • Avoiding straining, lifting over 10 pounds, bending over, and exercising
  • Sleeping with head slightly elevated
  • Avoiding nose blowing if packing is in place
  • Using nasal saline sprays to keep the nose moist 3

Special Considerations

• Recurrent bleeding: If the patient has recurrent bleeding despite prior treatment with packing or cautery, nasal endoscopy should be performed to identify the site of bleeding and guide further management 3
• Severe or persistent bleeding: Consider surgical options such as endoscopic arterial ligation (97% success rate) or endovascular embolization (~80% success rate) 1
• Risk factors: Document factors that increase bleeding severity including anticoagulant/antiplatelet use, bleeding disorders, or intranasal drug use 3

Warning Signs to Monitor

Instruct patients to seek immediate medical attention if they experience:

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath
• Loss of color around the skin of the nose
• Swelling of the face
• Diffuse skin rash 3

Pitfalls to Avoid

• Don't delay definitive treatment: Once the bleeding site is identified, proceed promptly with appropriate intervention rather than continuing with temporary measures
• Don't overlook posterior sources: If anterior measures fail, consider a posterior source requiring more aggressive management
• Don't forget to address underlying causes: Document and address risk factors that may lead to recurrence
• Don't neglect proper follow-up: Schedule follow-up within 3-5 days to assess for recurrence and ensure proper healing 1