What activities or treatments should be stopped during an episode of epistaxis?

Management of Epistaxis: Activities and Treatments to Stop

During an episode of epistaxis (nosebleed), antiplatelet and anticoagulant medications should be immediately discontinued as they contribute to persistent bleeding and impair hemostasis. 1

Initial Management Steps

• The patient should be seated with their head slightly forward to prevent blood from flowing into the airway or stomach 2, 3
• Apply continuous pressure to the soft lower part of the nose for 10-15 minutes 2, 3
• Breathe through the mouth and spit out blood instead of swallowing it 3
• Avoid ice packing as there is insufficient evidence supporting its use 2

Medication Management

• Immediately discontinue antiplatelet medications (such as clopidogrel) when epistaxis occurs 1
• If bleeding persists despite discontinuation of one antiplatelet agent, consider discontinuing all antiplatelet medications (including aspirin) 1
• Do not administer additional doses of anticoagulants while bleeding is active 2
• Avoid unnecessary reversal of anticoagulation due to increased risk of thrombotic events 2, 4

Additional Interventions

• If pressure application is insufficient, clean the nasal cavity of clots and apply a topical vasoconstrictor (oxymetazoline or phenylephrine) 3, 5
• Topical vasoconstrictors can stop bleeding in 65-75% of emergency department cases 3, 5
• Consider tranexamic acid application which promotes hemostasis in 78% of patients (compared to 35% with oxymetazoline) 5
• For persistent bleeding, nasal packing may be necessary 3, 6

Special Considerations

• Dual antiplatelet therapy (DAPT) should not be used to improve anginal symptoms, as there is no evidence supporting this practice 1
• In patients with stable coronary artery disease treated conservatively, there is no evidence supporting DAPT use 1
• Hypertension management is important, although the causal relationship between hypertension and epistaxis remains controversial 1

When to Seek Advanced Care

• If bleeding does not stop after 15 minutes of continuous pressure 2, 6
• For patients on anticoagulants or antiplatelet medications who experience persistent bleeding 2, 7
• When bleeding is severe or recurrent, requiring potential endoscopic evaluation or arterial intervention 3, 6

Resuming Antiplatelet Therapy

• Antiplatelet medications (like aspirin) can be restarted after bleeding has completely stopped for a few weeks 1
• The decision to restart should be based on the patient's thrombotic risk versus bleeding risk 4, 7

Common Pitfalls to Avoid

• Do not continue antiplatelet or anticoagulant medications during active epistaxis 1
• Avoid the routine practice of permanently withholding antiplatelet medications, as this can be associated with significant cardiovascular morbidity 4
• Do not use crioterapia (ice) for epistaxis management 2
• Avoid swallowing blood as it may cause nausea 3