What are the management options for epistaxis?

Management of Epistaxis (Nosebleeds)

The management of epistaxis should follow a stepwise approach starting with firm sustained compression to the lower third of the nose for at least 5 minutes, followed by identification of the bleeding site and appropriate intervention with topical vasoconstrictors, nasal cautery, or nasal packing based on severity and response to initial treatment. 1

Initial Assessment and Management

• At first contact, clinicians should distinguish patients requiring prompt management from those who don't, assessing for airway compromise, hemodynamic instability, or severe blood loss 1
• Position the patient sitting upright with head slightly tilted forward to prevent blood from entering the airway or stomach 2
• Apply firm sustained compression to the lower third of the nose for 5 minutes or longer, which is the recommended first-line treatment for active bleeding 1
• After removing any blood clots, perform anterior rhinoscopy to identify the bleeding site 1, 2

Treatment Based on Identified Bleeding Site

• For identified bleeding sites, use appropriate interventions including:
  • Topical vasoconstrictors (oxymetazoline, phenylephrine) which resolve 65-75% of nosebleeds 2, 3
  • Nasal cautery (chemical or electrical) after proper anesthetization of the site - restrict application only to active or suspected bleeding sites 1, 2
  • Moisturizing or lubricating agents to prevent recurrence 2

Management of Persistent Bleeding

• If initial measures fail, treat ongoing active bleeding with nasal packing 1
• Consider using resorbable packing for patients with suspected bleeding disorders or those using anticoagulant/antiplatelet medications 1
• Educate patients who undergo nasal packing about the type of packing placed, timing of removal (if not resorbable), postprocedure care, and warning signs that require reassessment 1

Advanced Management Options

• Perform nasal endoscopy to examine the nasal cavity and nasopharynx when bleeding is difficult to control or when there is concern for unrecognized pathology 1, 2
• Consider tranexamic acid (TXA) as an adjunct treatment:
  • Topical TXA has shown effectiveness in controlling bleeding within 10 minutes (70% success vs 30% with other agents) 4
  • Recent evidence suggests topical TXA reduces bleeding time and rebleeding compared to anterior nasal packing 5
• Evaluate candidacy for surgical arterial ligation or endovascular embolization for persistent or recurrent bleeding not controlled by packing or cauterization 1, 2

Special Considerations

• 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, 2
• For patients on anticoagulants, initiate first-line treatments before considering transfusion, reversal of anticoagulation, or withdrawal of medications 1, 6
• Do not use cryotherapy (ice) for epistaxis management as there is insufficient evidence supporting its efficacy 7, 6
• Assess for nasal and oral mucosal telangiectasias in patients with history of recurrent bilateral nosebleeds or family history of recurrent nosebleeds 1, 2

Prevention and Patient Education

• Educate patients about preventive measures (nasal moisturization, humidification), home treatment techniques, and indications to seek additional medical care 1, 2
• Recommend regular application of nasal emollients or petroleum jelly to prevent mucosal dryness 2, 3
• Document outcome of intervention within 30 days or document transition of care for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 1, 2

Anterior vs. Posterior Epistaxis

• Anterior epistaxis (90% of cases) is generally less severe and more easily managed with the above measures 3, 8
• Posterior epistaxis is more likely to require hospitalization and twice as likely to need nasal packing, often requiring referral to otolaryngology 8