What should be done for a 19-year-old male with nasal epistaxis who is taking resperidone (Risperdal) 2 mg bd, haloperidol (Haldol) 10 mg hs, valproate (Depakote) 500 mg bd, propanolol (Inderal) 40 mg od, flunarizine 10 mg od, and trihexyphenidyl (Artane) 2 mg od?

Management of Nasal Epistaxis in a 19-Year-Old Male on Multiple Psychiatric Medications

For this 19-year-old male with nasal epistaxis who is on multiple psychiatric medications, first-line treatment should focus on direct nasal compression for 10-15 minutes while sitting upright with the head slightly tilted forward, followed by application of topical vasoconstrictors if bleeding persists. 1, 2

Initial Management

• 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 (soft part) of the nose for at least 10-15 minutes without checking if bleeding has stopped 3, 2
• Have the patient breathe through the mouth and spit out any blood rather than swallowing it 3
• This simple compression technique resolves most nosebleeds and should be the initial intervention 2, 4

If Bleeding Persists After Initial Compression

• Clear any blood clots from the nose 2
• Apply a topical vasoconstrictor such as oxymetazoline or phenylephrine spray (2 sprays in the bleeding nostril) 3, 2
• Continue compression for an additional 5 minutes 3
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 2

Medication Considerations

• The patient's current medications (risperidone, haloperidol, valproate, propranolol, flunarizine, and trihexyphenidyl) are not typically associated with significant bleeding risk like anticoagulants or antiplatelets 5
• No need to discontinue or adjust these psychiatric medications for an isolated epistaxis episode 1
• First-line treatments should be initiated before considering any medication adjustments 1, 3

Prevention of Recurrence

• Once bleeding has stopped, apply hydrating or lubricating agents such as petroleum jelly to prevent recurrence 3, 2
• Recommend regular use of saline nasal sprays to keep the nasal mucosa moist 3
• Consider using a humidifier, especially in dry environments 3

When to Seek Further Medical Attention

• If bleeding does not stop after 15 minutes of continuous pressure 3
• If the patient experiences dizziness due to blood loss 3
• If bleeding is severe (duration >30 minutes over a 24-hour period) 3
• If the patient shows signs of hemodynamic instability such as tachycardia or hypotension 2

Advanced Treatment Options (if necessary)

• If epistaxis persists despite initial measures, evaluation by an ENT specialist may be necessary 3
• Options such as nasal cauterization, nasal packing, or in severe cases, arterial ligation may be considered 3, 2
• Nasal endoscopy may be performed to examine the nasal cavity and nasopharynx when bleeding is difficult to control 2

Common Errors to Avoid

• Insufficient compression time: compression must be maintained for at least 10-15 minutes without checking if bleeding has stopped 3, 6
• Incorrect head position: tilting head backward can cause blood to flow into the throat and potentially be aspirated 6
• Neglecting prevention: not treating underlying nasal mucosa dryness can lead to recurrent episodes 3