What is the initial management for a patient presenting with epistaxis (nosebleed)?

Initial Management of Epistaxis (Nosebleed)

The initial management for a patient presenting with epistaxis should be firm sustained compression to the lower third of the nose for 5 minutes or longer. 1

Assessment and Immediate Management

• At the time of initial contact, clinicians should distinguish patients who require prompt management from those who do not 1
• For active bleeding, assess for:
  • Airway compromise from bleeding into the oropharynx 1
  • Hemodynamic instability due to blood loss 1
  • Severity of bleeding (minor vs. severe) 1

First-Line Treatment: Nasal Compression

• Apply firm sustained compression to the lower third (soft part) of the nose for at least 5 minutes 1
• The patient should be positioned leaning slightly forward to reduce the risk of blood aspiration 2
• This simple measure stops bleeding in the majority of cases and should be attempted before more invasive interventions 1

Further Management Based on Response

If Bleeding Continues After Compression:

1. Identify the Bleeding Site:

   • Perform anterior rhinoscopy after removing any blood clots 1
   • Look for the source of bleeding, commonly from Kiesselbach's plexus in the anterior nasal septum 1

2. Appropriate Interventions for Identified Bleeding Site:

   • Apply topical vasoconstrictors (e.g., oxymetazoline, phenylephrine) which can stop 65-75% of nosebleeds 1, 3
   • Consider nasal cautery (chemical or electrical) for localized bleeding sites 1
   • Use moisturizing or lubricating agents after bleeding is controlled to prevent recurrence 1

3. Nasal Packing:

   • If bleeding cannot be controlled with the above measures, apply nasal packing 1
   • Use resorbable packing for patients with suspected bleeding disorders or those on anticoagulant/antiplatelet medications 1
   • Educate patients about the type of packing, removal plan (if not resorbable), and warning signs requiring reassessment 1

Special Considerations

• Risk Factors: Document factors that increase bleeding risk, including:

  • Personal or family history of bleeding disorders 1
  • Use of anticoagulant or antiplatelet medications 1
  • Intranasal drug use 1
  • Hypertension, prior nasal surgery, or trauma 1

• For Difficult-to-Control Bleeding:

  • Consider nasal endoscopy to examine the nasal cavity and nasopharynx 1
  • Posterior epistaxis (less common but more severe) may require more aggressive management and referral to an otolaryngologist 4, 5

Common Pitfalls to Avoid

• Incorrect compression technique: Many healthcare providers incorrectly apply pressure to the nasal bones rather than the soft cartilaginous portion of the nose 2
• Improper head positioning: Tilting the head backward increases the risk of blood aspiration; the head should be tilted slightly forward 2
• Premature termination of compression: Compression should be maintained for at least 5 minutes without checking if bleeding has stopped 1
• Overlooking anticoagulant medications: In the absence of life-threatening bleeding, first-line treatments should be initiated prior to considering reversal or withdrawal of anticoagulation 1

Patient Education

• Instruct patients on proper home management techniques for future episodes 1
• Advise on preventive measures such as nasal saline sprays and humidification 1
• Provide clear guidance on when to seek additional medical care 1