How do you manage a severe epistaxis?

Management of Severe Epistaxis (Nosebleed)

The most effective first-line treatment for a profuse nosebleed is firm sustained compression to the lower third (soft part) of the nose for at least 10-15 minutes while sitting upright with the head slightly tilted forward. 1, 2

Initial Management

• Position the patient sitting upright with head slightly tilted forward to prevent blood from entering the airway or stomach 3, 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 1, 2
• The patient should breathe through their mouth and spit out any blood rather than swallow it 3
• This approach alone resolves 90-95% of nosebleeds in most cases 4

If Bleeding Persists After Initial Compression

• Clear any blood clots from the nose 3
• Apply a topical vasoconstrictor such as oxymetazoline or phenylephrine spray (2 sprays in the bleeding nostril) 1, 2, 5
• Resume compression for another 5-10 minutes 3
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 2, 5

Identifying the Bleeding Site

• If bleeding continues, perform anterior rhinoscopy to identify the source of bleeding after removing any blood clots 1
• When the bleeding site is identified, appropriate interventions may include:
  • Topical vasoconstrictors (as mentioned above) 1, 2
  • Nasal cautery (after proper anesthesia of the site) 1, 5
  • Moisturizing or lubricating agents 1, 3

Advanced Management (If Initial Measures Fail)

• If bleeding continues despite the above measures, nasal packing should be considered 1
• For severe cases requiring advanced intervention, refer to an otolaryngologist who can perform:
  • Nasal endoscopy to identify difficult-to-visualize bleeding sites 1, 2
  • More definitive treatments such as endoscopic cauterization or arterial ligation 2, 5
  • Tranexamic acid may be considered as it promotes hemostasis in 78% of patients versus 35% with oxymetazoline alone 5, 6

Special Considerations

• For patients on anticoagulants or antiplatelet medications, do not discontinue these medications as first-line treatment 1, 3
• In the absence of life-threatening bleeding, initiate the standard first-line treatments before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications 1, 7
• For patients with recurrent epistaxis, prevention is key - apply petroleum jelly or other lubricating agents to keep the nasal mucosa moist 3, 2

When to Seek Emergency Care

• If bleeding does not stop after 15 minutes of continuous pressure 3, 2
• If the patient experiences dizziness, lightheadedness, or signs of significant blood loss 2
• If bleeding is severe (duration >30 minutes over a 24-hour period) 1, 2
• If the patient shows signs of hemodynamic instability such as tachycardia or hypotension 1, 2

Common Pitfalls to Avoid

• Insufficient compression time - compression must be maintained continuously for at least 10-15 minutes 3, 2
• Tilting the head backward, which can cause blood to flow into the throat and be aspirated 3, 4
• Checking too frequently if bleeding has stopped, which disrupts clot formation 2
• Neglecting prevention of recurrence by not addressing underlying nasal mucosa dryness 3, 2