How to manage nosebleeds in patients with hypertension?

Management of Nosebleeds in Hypertensive Patients

Do not routinely lower blood pressure acutely in patients presenting with epistaxis, as there is no causal evidence that hypertension causes nosebleeds and rapid blood pressure reduction risks end-organ damage. 1

Initial Assessment and Blood Pressure Considerations

Blood Pressure Management

• Monitor blood pressure but avoid routine acute reduction during active epistaxis, as excessive lowering may cause renal, cerebral, or coronary ischemia 1
• The relationship between hypertension and epistaxis is associative, not causal—hypertension prevalence in epistaxis patients ranges from 24-64%, but no causal link has been established 2
• One retrospective study found higher systolic blood pressure (181.3 vs 156.6 mm Hg) associated with persistent bleeding, but this does not justify routine acute BP lowering 3
• Base blood pressure control decisions on: severity of bleeding, inability to control hemorrhage with local measures, individual patient comorbidities, and potential risks of rapid BP reduction 1

Risk Factor Assessment

• Obtain directed history including: onset, duration, frequency of bleeding; other bleeding sites; current medications (especially anticoagulants/antiplatelets); intranasal medications; nasal oxygen or CPAP use; and prior nasal surgery 1
• Check INR in patients on warfarin to evaluate therapeutic range—supratherapeutic levels may require specialty consultation, medication discontinuation, or reversal agents for severe refractory bleeding 1
• Intranasal corticosteroids increase nosebleed risk 2.74-fold and should be considered for cessation in recurrent cases 1

Immediate Management Algorithm

First-Line Treatment (All Patients)

1. Patient positioning: Sit upright with head tilted slightly forward to prevent blood aspiration 2, 4
2. Nasal compression: Apply firm sustained pressure to the soft lower third of the nose for at least 5 minutes, continuing up to 15 minutes if bleeding slows 1, 2
3. Remove blood clots by gentle nose blowing or suction to visualize the bleeding site 1

Anterior Rhinoscopy and Site Identification

• Perform anterior rhinoscopy after clot removal to identify the bleeding source—this is essential for targeted treatment 1, 2
• Most bleeds originate from Kiesselbach's plexus on the anterior nasal septum 1, 2

Treatment Options for Identified Anterior Bleeding Site

The clinician should offer one or more of the following: topical vasoconstrictors, nasal cautery, and/or moisturizing agents 1

Topical Vasoconstrictors

• Oxymetazoline or phenylephrine (over-the-counter nasal sprays) control 65-75% of nosebleeds 1, 5
• Application method: Blow nose to clear clots, spray 2 sprays in bleeding nostril, continue holding pressure for 5 minutes, may repeat once 1
• Caution in hypertensive patients: These agents may increase cardiac complications or systemic blood pressure, though one trial showed no mean arterial pressure changes in patients without cardiovascular disease 1

Nasal Cautery

• Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 5
• Restrict cautery to the active bleeding site only to avoid excessive nasal lining or septal damage 1, 2
• Usually performed with local anesthesia in office settings 1

Topical Tranexamic Acid (Emerging Option)

• Topical tranexamic acid promotes hemostasis in 78% of patients versus 35% with oxymetazoline and 31% with nasal packing 5
• Moderate-quality evidence shows topical tranexamic acid is probably better than other topical agents in stopping bleeding within 10 minutes (70% vs 30% success rate) 6
• When combined with usual care, reduces re-bleeding risk from 67% to 47% within 10 days 6

Nasal Packing (If Initial Measures Fail)

• Resorbable packing materials (e.g., Nasopore) are preferred as they avoid trauma from removal and reduce re-bleeding risk 1, 5
• Newer hemostatic materials (Surgicel, Floseal, Spongostan, fibrin glue) are more effective with fewer complications than traditional petroleum jelly or BIPP gauze 5
• Non-resorbable options include PVA tampons (Merocel) or balloon devices (Rapid-Rhino) 5

Preventive Measures and Patient Education

After Bleeding Control

• Apply moisturizing agents (nasal saline gel/spray) and use humidifiers to prevent recurrence 1
• Avoid digital trauma (nose picking), vigorous nose blowing, and trauma to the healing area 1
• Continue nasal saline and humidification to maintain moist nasal mucosa 1

Anticoagulation Considerations

• Do not routinely discontinue anticoagulants/antiplatelets for nosebleeds unless bleeding is severe and refractory to initial therapies 1
• These medications increase nosebleed risk but are often medically necessary 1
• Consider specialty consultation for medication management in severe cases 1

Refractory Cases

Advanced Interventions

• Endoscopic sphenopalatine artery (SPA) ligation is more effective than conventional nasal packing (97% vs 62% success) 5
• Endoscopic cauterization is more effective than ligation alone 5
• Arterial embolization using gelatin sponge, foam, PVA, or coils achieves 80% success rate with comparable efficacy to surgical methods 5
• Early sphenopalatine artery ligation may improve outcomes and reduce costs in severe epistaxis 1

Critical Pitfalls to Avoid

• Never aggressively lower blood pressure in acute epistaxis without considering end-organ damage risk 1
• Avoid excessive or bilateral cautery that can damage the nasal septum 1
• Do not tilt head backward—this increases aspiration risk and does not improve bleeding control 2, 4
• Do not apply compression to nasal bridge—pressure must be on the soft lower third of the nose where vessels are located 4
• Document outcomes within 30 days for patients treated with nonresorbable packing, surgery, or arterial procedures 1