What is the treatment for epistaxis (nose bleed)?

Treatment for Epistaxis (Nosebleed)

For an active nosebleed, sit upright with head tilted slightly forward and apply firm, sustained compression to the soft lower third of the nose for 10-15 minutes continuously without checking if bleeding has stopped. 1

Immediate First-Line Management

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach, which can cause choking or vomiting 1
• Apply firm, continuous pressure by pinching the soft lower third of the nose (not the bony bridge) for a minimum of 10-15 minutes without releasing to check 1
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 1, 2
• Nasal compression alone stops bleeding in the vast majority of cases (approximately 90-95% when done correctly), including 20% of emergency department cases 1

If Bleeding Continues After 15 Minutes

• Clear any blood clots from the nose by having the patient blow gently, then apply topical vasoconstrictor spray 1
• Use oxymetazoline (Afrin) or phenylephrine nasal spray: spray 2 times into the bleeding nostril, then resume firm compression for another 5 minutes 1, 3
• This approach stops 65-75% of nosebleeds that present for medical attention 1, 4
• May repeat vasoconstrictor application once if needed 1

After Bleeding Stops: Prevention of Recurrence

• Apply nasal saline gel or petroleum jelly 1-3 times daily to keep nasal mucosa moisturized 1
• Use a humidifier at bedside, especially in dry climates or during winter months 1, 5
• Avoid nose blowing, strenuous activity, and heavy lifting for at least one week after the bleeding episode 1, 5
• Do not insert tissues or cotton into the nostrils 5, 2

When to Seek Immediate Medical Attention

• Bleeding does not stop after 15 minutes of continuous, proper compression 1
• Patient becomes lightheaded, dizzy, or shows signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension) 1
• Bleeding duration exceeds 30 minutes over a 24-hour period 1
• Epistaxis due to trauma with signs of brain injury, obvious nasal deformity, or facial fracture 1
• Patients taking anticoagulants or antiplatelet medications should seek medical evaluation unless bleeding has completely stopped 1
• Patients with known bleeding disorders or history of requiring hospitalization/transfusion for nosebleeds 1

Advanced Medical Interventions (When Simple Measures Fail)

If initial compression and vasoconstrictors fail, the following interventions may be performed by trained clinicians:

Nasal Cautery

• The bleeding site should be anesthetized with topical lidocaine or tetracaine before cautery 1
• Restrict cautery application only to the active or suspected bleeding site to minimize tissue damage 1
• Electrocautery is more effective than chemical cautery (silver nitrate) with fewer recurrences (14.5% vs 35.1%) 1, 4
• Avoid bilateral septal cautery to minimize risk of septal perforation 1

Nasal Packing

• Consider if bleeding continues despite compression, vasoconstrictors, and cautery 1
• Resorbable packing materials are preferred to avoid trauma during removal 1
• Newer hemostatic materials (Floseal, Surgicel, gelatin sponge) are more effective with fewer complications than traditional packing 4

Tranexamic Acid (TXA)

• Topical TXA can be used for acute control, promoting hemostasis in 78% of patients compared to 35% with oxymetazoline alone 4
• More effective than anterior nasal packing in some studies, particularly for patients on antiplatelet medications 1

Critical Pitfalls to Avoid

• Insufficient compression time: Most failures occur because pressure is released too early to check if bleeding stopped 1, 2
• Tilting head backward: This causes blood to flow into the throat and stomach, risking aspiration and vomiting 1, 2
• Compressing the bony bridge instead of the soft lower third of the nose where the bleeding vessels are located 1
• Using ice or cold compresses: Evidence does not support cryotherapy for epistaxis management 1
• Inserting tissues or cotton into nostrils, which can be aspirated or cause rebleeding upon removal 5, 2

Special Populations

Patients on Anticoagulants

• Do not discontinue anticoagulation without consulting the prescribing physician, as these medications treat serious conditions 1
• If bleeding is severe, hold the next dose until evaluated, but seek evaluation immediately 1
• Use resorbable packing if nasal packing is required 1

Children

• Same management principles apply: compression for 5-15 minutes with head forward 5, 2
• Digital trauma (nose picking) is the most common cause in children 5
• Keep fingernails trimmed and use regular nasal saline to prevent recurrence 5
• Young children or uncooperative patients may require sedation for cautery 1