What is the management of epistaxis?

Management of Epistaxis

The management of epistaxis should begin with firm sustained compression to the lower third of the nose for at least 10-15 minutes while the patient sits upright with the head slightly tilted forward. 1, 2

Initial Assessment and Management

• Immediately distinguish patients requiring prompt management from those who don't 3
• Position the patient sitting upright with head slightly tilted forward to prevent blood from entering the airway or stomach 1, 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, 1
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 4, 2

If Bleeding Persists After Initial Compression

• Clear any clots from the nasal cavity 2
• Apply a topical vasoconstrictor such as oxymetazoline or phenylephrine spray (2 sprays in the bleeding nostril) 1, 5
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 5
• Continue compression for an additional 5 minutes after applying the vasoconstrictor 4

Advanced Management Options

• For persistent bleeding, consider nasal packing 2
• For patients on anticoagulants or antiplatelet medications, use resorbable packing material 3, 4, 2
• In the absence of life-threatening bleeding, initiate first-line treatments prior to considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 3, 4
• For recurrent or persistent bleeding not controlled by packing or cauterization, evaluate for surgical arterial ligation or endovascular embolization 3, 2

Site-Specific Management

• Treat patients with an identified site of bleeding with appropriate interventions including topical vasoconstrictors, nasal cautery, and moisturizing agents 3
• Anterior epistaxis (most common) can typically be managed with the above measures 6
• Posterior epistaxis (more severe) may require more aggressive management including posterior packing and hospitalization 7, 6

Prevention of Recurrence

• Once bleeding has stopped, apply hydrating or lubricating agents such as petroleum jelly to prevent recurrence 1, 2
• Recommend regular use of saline nasal sprays to keep the nasal mucosa moist 1, 4
• Using a humidifier, especially in dry environments, can also be considered 4
• Document factors that increase frequency or severity of bleeding (bleeding disorders, anticoagulant/antiplatelet medications, intranasal drug use) 3

When to Seek Further Medical Attention

• If bleeding does not stop after 15 minutes of continuous pressure 1, 4
• If the patient experiences dizziness due to blood loss 4
• If bleeding is severe (duration >30 minutes over a 24-hour period) 1, 4
• If the patient shows signs of hemodynamic instability such as tachycardia or hypotension 4, 8

Emerging Treatment Options

• Recent research shows topical application of tranexamic acid may be more effective than anterior nasal packing, reducing bleeding time and number of rebleeds 9
• Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) may be more effective with fewer complications than traditional packing materials 5

Common Pitfalls to Avoid

• Insufficient compression time - compression must be maintained for at least 10-15 minutes without checking if bleeding has stopped 1, 2
• Neglecting prevention - not treating underlying nasal mucosa dryness can lead to recurrent episodes 4
• Premature consideration of anticoagulation reversal before trying first-line treatments 3, 4