How to manage a patient with severe epistaxis and hypertensive crisis (blood pressure 200/110)?

Management of Severe Epistaxis with Hypertensive Crisis (BP 200/110)

Control the epistaxis first with direct local measures—do NOT aggressively lower blood pressure acutely during active bleeding, as this can cause end-organ ischemia in patients with chronic hypertension. 1

Immediate Epistaxis Control (Priority #1)

Initial Direct Measures

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 2, 3
• 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 2, 1, 3
• Patient should breathe through mouth and spit out blood rather than swallowing it 2

If Bleeding Persists After Compression

• Clear clots from the nose, then apply topical vasoconstrictor (oxymetazoline or phenylephrine spray—2 sprays in the bleeding nostril) and continue compression for 5 minutes 2, 3
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 2
• Consider nasal packing with resorbable material if bleeding continues, especially given the likely presence of chronic hypertension in this patient 1, 3

Advanced Interventions if Needed

• ENT consultation for nasal endoscopy to identify posterior bleeding sources, which are more common in elderly hypertensive patients 1, 4
• Endoscopic sphenopalatine artery ligation controls intractable posterior epistaxis with high success rates 4
• Nasal cauterization restricted to the active bleeding site if identified 1

Blood Pressure Management (Secondary Priority)

Critical Principle: Avoid Aggressive Acute Lowering

• Do NOT routinely lower blood pressure acutely during active epistaxis—excessive reduction can cause or worsen renal, cerebral, or coronary ischemia 1
• This is a common and dangerous pitfall, particularly in elderly patients with chronic hypertension who have adapted cerebral autoregulation 1

When to Consider BP Control

• Monitor blood pressure but base control decisions on: bleeding severity, inability to control bleeding with local measures, individual comorbidities, and risks of BP reduction 1
• The relationship between epistaxis and hypertension remains controversial—prevalence of hypertension in epistaxis patients ranges from 17-67%, but causality is unproven 5
• If BP control is deemed necessary after bleeding is controlled, use gradual reduction with IV labetalol (initial 20mg IV bolus, then 40-80mg every 10 minutes up to 300mg cumulative dose, or continuous infusion) 6

Post-Bleeding BP Management

• Once epistaxis is controlled, monitor BP at the waning phase and control medically to reduce risk of recurrence 7
• If persistent hypertension after severe epistaxis resolves, prescribe cardiovascular evaluation to screen for underlying hypertensive disease 7

Assessment of Risk Factors

High-Risk Features Requiring Hospitalization

• Age >65 years (OR 1.02 per year increase) 8
• Male sex (OR 2.07) 8
• Hypertension (OR 1.76) 8
• Anticoagulation/antiplatelet therapy (OR 2.53 for anticoagulation, OR 1.65 for antiplatelet) 8
• Posterior bleeding source—more common in older hypertensive patients, more difficult to control, higher hospitalization likelihood 1

Medication Review

• Check if patient is on anticoagulants (warfarin)—verify INR and consider reversal agents only for severe refractory bleeding 1
• Antiplatelet agents (aspirin, clopidogrel) can cause persistent epistaxis but should not be discontinued unless bleeding cannot be controlled with local measures 5
• First-line local treatments should be initiated before considering medication adjustments 2, 3

Prevention of Recurrence

• Once bleeding stops, apply petroleum jelly or other lubricating agents to the nasal mucosa 2, 3
• Recommend saline nasal sprays to keep mucosa moist 2
• Humidifier use in dry environments 2

Indications for Hospitalization

• Bleeding not controlled after 15 minutes of continuous pressure 2, 3
• Hemodynamic instability (tachycardia, hypotension) 2, 3
• Severe bleeding (duration >30 minutes over 24 hours) 2, 3
• Hemoglobin drop >1g/dL (though transfusion rarely needed—only 7 of 34 patients in one series) 8
• Combination of risk factors: elderly male with hypertension on anticoagulation 8

Common Pitfalls to Avoid

• Insufficient compression time—must maintain for full 10-15 minutes without checking 2
• Aggressively lowering BP acutely—can cause end-organ ischemia 1
• Overlooking anticoagulation status—check INR if on warfarin 1
• Neglecting posterior source evaluation—elderly hypertensive patients require endoscopic examination 1