What are the treatment options for epistaxis (nosebleed)?

Treatment Options for Epistaxis (Nosebleeds)

For most cases of nosebleeds, first-line treatment should involve firm sustained compression to the lower third of the nose for at least 5 minutes, and if bleeding continues, compression should be maintained for a full 15 minutes. 1

Initial Management

• Distinguish patients requiring prompt management from those who don't - assess for airway compromise, hemodynamic instability, or severe blood loss that would require emergency department evaluation 1
• Position the patient sitting with head slightly forward to prevent blood from draining into the throat 2
• Apply firm sustained compression to the soft part (lower third) of the nose for 5-15 minutes continuously 1, 2
• Clear any blood clots before attempting to identify the bleeding site 1
• Perform anterior rhinoscopy to identify the source of bleeding after clot removal 1

First-Line Interventions

• For active bleeding that persists after compression, use topical vasoconstrictors such as oxymetazoline or phenylephrine nasal spray, which can stop 65-75% of nosebleeds 1, 3
  • Apply by first clearing clots, then spraying twice in the bleeding nostril and continuing compression for 5 minutes 2
• For identified bleeding sites, treatment options include:
  • Topical vasoconstrictors (as above) 1
  • Nasal cautery (chemical or electrical) after proper anesthesia of the site 1
  • Moisturizing or lubricating agents to prevent recurrence 1

Advanced Interventions

• For persistent bleeding, nasal packing should be used 1
  • Options include non-absorbable materials (petroleum jelly, BIPP gauze, PVA nasal tampons) or absorbable materials (Nasopore) 3
  • For patients on anticoagulants or with bleeding disorders, use resorbable packing 1
  • Educate patients about the type of packing placed, removal timing (if non-resorbable), and post-procedure care 1
• For difficult cases requiring specialized management:
  • Nasal endoscopy should be performed to identify bleeding sites when anterior rhinoscopy is insufficient 1
  • For recurrent bleeding despite prior treatment with packing or cautery, referral for endoscopic evaluation is recommended 1

Management for Refractory Cases

• Evaluate candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or cauterization 1
• In the absence of life-threatening bleeding, initiate first-line treatments before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications 1

Prevention of Recurrence

• Educate patients about preventive measures 1:
  • Avoid digital trauma (nose picking) and vigorous nose blowing 1
  • Use nasal saline and moisturizing gels to lubricate the nasal mucosa 1, 4
  • Consider using a humidifier, especially during dry seasons or in dry environments 4
• After cauterization, instruct patients to avoid nose blowing, strenuous activity, and heavy lifting for at least a week 1, 4

Special Considerations

• For children, digital trauma (nose picking) is the most common cause of nosebleeds 4
• For patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds, assess for nasal and oral mucosal telangiectasias (potential hereditary hemorrhagic telangiectasia) 1
• Document outcomes within 30 days for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 1

When to Seek Additional Medical Care

• Bleeding that doesn't stop after 15 minutes of proper compression 2
• Signs of significant blood loss (dizziness, weakness, tachycardia) 2
• Recurrent nosebleeds despite preventative measures 4
• Nosebleeds associated with trauma, foreign bodies, or suspected underlying medical conditions 4