What is the first line of management for a patient with epistaxis due to viral Upper Respiratory Tract Infection (URTI)?

First-Line Management of Epistaxis Due to Viral URTI

The first-line management for epistaxis due to viral Upper Respiratory Tract Infection (URTI) is firm sustained compression to the lower third of the nose for 5 minutes or longer, with the head slightly tilted forward.1, 2

Initial Management Algorithm

Step 1: Immediate Measures

• Apply firm sustained compression to the lower third of the nose (soft part) for at least 5-10 minutes with the patient's head tilted slightly forward 1, 2
• Instruct the patient to breathe through the mouth and spit out any blood rather than swallowing it 2
• Compression alone is sufficient to stop bleeding in most cases of epistaxis related to viral URTI 2

Step 2: If Bleeding Persists After Initial Compression

• Apply a topical vasoconstrictor such as oxymetazoline or phenylephrine, which resolves 65-75% of nosebleeds 1, 3
• Continue compression for another 5-10 minutes after applying the vasoconstrictor 1
• If the bleeding site is visible and accessible, targeted treatment with nasal cautery may be considered 1

Step 3: Prevention of Recurrence

• Once bleeding has stopped, apply moisturizing or lubricating agents such as petroleum jelly to prevent recurrences 1, 2
• Recommend saline nasal sprays to keep the nasal mucosa humid 2, 4
• Consider use of a humidifier, especially in dry environments 2

Rationale and Evidence

• Viral URTIs cause inflammation and dryness of the nasal mucosa, making it more susceptible to bleeding 1
• The anterior nasal septum (Kiesselbach's plexus) is the most common site of bleeding in URTI-related epistaxis 1
• Nasal compression works by applying direct pressure to the bleeding vessels, allowing clot formation 1
• Studies show that 90-95% of nosebleeds stop with proper compression techniques 5
• Saline nasal irrigation has been shown to be effective in alleviating symptoms of viral URTIs and may help prevent epistaxis by maintaining mucosal moisture 6

Special Considerations

• Avoid having the patient tilt their head backward, as this can cause blood to flow into the posterior pharynx, potentially leading to aspiration 5
• Advise patients to avoid nasal picking, forceful nose blowing, and strenuous activity for 24 hours after the bleeding stops 1
• Recommend avoiding medications that may increase bleeding risk, such as aspirin and ibuprofen; acetaminophen can be used instead 1

When to Seek Further Medical Attention

• If bleeding does not stop after 15 minutes of continuous pressure 2
• If bleeding is severe (duration >30 minutes in a 24-hour period) 2
• If the patient experiences dizziness, indicating significant blood loss 2
• If there are signs of hemodynamic instability such as tachycardia or hypotension 1

Common Pitfalls to Avoid

• Incorrect compression technique: Many healthcare providers incorrectly identify the proper site for nasal compression 5
• Insufficient compression time: Compression should be maintained for at least 5 minutes without checking if bleeding has stopped 1
• Neglecting prevention: Failure to address the underlying dryness of nasal mucosa can lead to recurrent episodes 2, 4
• Overuse of vasoconstrictors: Prolonged use of topical decongestants can lead to rebound congestion and worsen symptoms 1

Proper first-line management with appropriate compression technique and subsequent preventive measures can effectively manage most cases of epistaxis due to viral URTI without the need for more invasive interventions.