What is the first line of treatment for epistaxis (nosebleed)?

First-Line Treatment for Epistaxis (Nosebleed)

The first-line treatment for epistaxis is firm sustained compression to the lower third of the nose for at least 5 minutes. 1

Initial Management Algorithm

1. Patient Positioning and Compression

   • Seat the patient with head tilted slightly forward to prevent blood from flowing into the airway or stomach 2
   • Apply firm sustained compression to the soft lower third of the nose for 5-15 minutes 1
   • Patient should breathe through mouth and spit out blood rather than swallowing it 2
   • Compression alone resolves the majority of epistaxis cases 2, 1

2. If Bleeding Persists After Initial Compression

   • Clear any blood clots from the nasal cavity 1
   • Apply a topical vasoconstrictor such as oxymetazoline or phenylephrine 1, 3
   • Topical vasoconstrictors stop 65-75% of nosebleeds treated in emergency settings 3
   • Continue compression for at least 5 additional minutes after applying vasoconstrictor 4

3. Identification of Bleeding Site

   • Perform anterior rhinoscopy to identify the source of bleeding 1
   • If a specific bleeding site is identified, consider appropriate intervention based on location 1

Secondary Interventions (If First-Line Fails)

• For Identified Bleeding Sites:

  • Apply topical vasoconstrictors 1, 3
  • Consider nasal cautery (chemical or electrical) 1, 3
  • Apply moisturizing or lubricating agents 1, 2

• For Persistent Bleeding:

  • Consider nasal packing 1
  • For patients on anticoagulants or with bleeding disorders, use resorbable packing 5
  • Consider topical tranexamic acid, which has shown effectiveness in controlling epistaxis 6, 7

Prevention of Recurrence

• Apply moisturizing or lubricating agents (such as petroleum jelly) to the nasal mucosa 2, 5
• Regular use of saline nasal sprays to keep the nasal mucosa moist 2, 5
• Consider using a humidifier, especially in dry environments 4
• Educate patients about preventive measures and home treatment 1, 5

Common Pitfalls to Avoid

• Insufficient compression time: Many patients check too early if bleeding has stopped. Maintain continuous pressure for the full recommended duration (minimum 5 minutes) 1, 4
• Incorrect compression location: Ensure pressure is applied to the soft lower third of the nose, not the nasal bridge 1
• Tilting head backward: This position allows blood to flow into the pharynx and may cause aspiration or nausea 2
• Neglecting to address underlying causes: Document factors that increase bleeding frequency/severity, including use of anticoagulants or antiplatelet medications 1, 5

When to Consider Specialist Referral

• Bleeding that persists despite initial measures 5
• Recurrent epistaxis despite appropriate interventions 1
• Suspicion of posterior bleeding source 1
• Signs of significant blood loss (tachycardia, hypotension) 4
• Need for nasal endoscopy to identify obscure bleeding sites 1

Special Considerations

• Patients on Anticoagulants: Continue first-line treatments before considering reversal or withdrawal of anticoagulation in the absence of life-threatening bleeding 5
• Recurrent Epistaxis: Consider nasal endoscopy to identify the bleeding site and guide further management 5
• Posterior Epistaxis: More likely to require hospitalization and specialized interventions 8