Management of Frequent Nosebleeds (Epistaxis)
The most effective approach to managing patients with frequent epistaxis is to first distinguish those requiring prompt management, then apply firm sustained compression to the lower third of the nose for at least 5 minutes, followed by appropriate interventions based on the identified bleeding site. 1
Initial Assessment and Management
Determining Severity
- Immediately assess whether the patient requires prompt management based on bleeding severity, airway compromise risk, and hemodynamic stability 1
- Document factors that increase bleeding frequency or severity, including personal/family history of bleeding disorders, use of anticoagulant/antiplatelet medications, and intranasal drug use 1
- Position the patient sitting upright with head slightly tilted forward to prevent blood from entering the airway or stomach 2
First-Line Treatment
- Apply firm sustained compression to the lower third of the nose for 5 minutes or longer 1
- After removing any blood clots, perform anterior rhinoscopy to identify the bleeding site 1
- For active bleeding where the site cannot be identified despite compression, proceed to nasal packing 1
Treatment Based on Identified Bleeding Site
Site-Specific Interventions
- For identified bleeding sites, use appropriate interventions including:
Nasal Packing Considerations
- Use resorbable packing materials for patients with suspected bleeding disorders or those on anticoagulation/antiplatelet medications 1
- Educate patients receiving nasal packing about:
- Type of packing placed
- Timing and plan for removal (if non-resorbable)
- Post-procedure care
- Signs/symptoms requiring prompt reassessment 1
Management of Persistent or Recurrent Bleeding
Advanced Assessment
- Perform nasal endoscopy to examine the nasal cavity and nasopharynx when:
- Bleeding is difficult to control
- There is concern for unrecognized pathology
- Patient has recurrent nasal bleeding despite prior treatment with packing or cautery 1
Advanced Interventions
- For persistent or recurrent bleeding not controlled by packing or cauterization, evaluate candidacy for:
- Surgical arterial ligation
- Endovascular embolization 1
- Consider tranexamic acid (oral or topical) which can reduce the risk of re-bleeding from 67% to 47% compared to placebo 5
Special Considerations
Anticoagulated Patients
- In the absence of life-threatening bleeding, initiate first-line treatments before considering:
Hereditary Hemorrhagic Telangiectasia (HHT)
- Assess for nasal and oral mucosal telangiectasias in patients with:
- History of recurrent bilateral nosebleeds
- Family history of recurrent nosebleeds 1
Prevention and Patient Education
Preventive Measures
- Educate patients and caregivers about:
- Recommend regular application of nasal emollients or petroleum jelly to prevent mucosal dryness 3
Follow-up
- Document outcome of intervention within 30 days or document transition of care for patients treated with:
- Non-resorbable packing
- Surgery
- Arterial ligation/embolization 1
Common Pitfalls to Avoid
- Applying ice to the nose or bridge of nose is not supported by evidence 2
- Tilting the head backward increases risk of blood aspiration and should be avoided 2, 6
- Delaying referral to specialists for patients with recurrent, severe, or unilateral epistaxis that may indicate underlying pathology 3
- Unnecessary reversal of anticoagulation, which increases thrombotic risk 2