Management of Epistaxis in the Elderly
Elderly patients with epistaxis should be positioned sitting upright with head tilted slightly forward and firm sustained compression applied to the soft lower third of the nose for 10-15 minutes without interruption, which is the essential first-line intervention that resolves the majority of nosebleeds. 1
Understanding the Elevated Risk in Elderly Patients
Elderly patients face dramatically higher risk for severe epistaxis requiring emergency intervention. Patients aged 76-85 years are 2.37 times more likely to present to emergency departments compared to those under 65, while those over 85 years are 3.24 times more likely. 2 This age group experiences posterior epistaxis (5-10% of cases) more frequently, which originates from posterior sites on the lateral nasal wall or septum not visible by anterior rhinoscopy and is significantly more difficult to control. 2 Notably, posterior epistaxis carries a 30-day all-cause mortality rate of 3.4%. 2
Critical risk factors to document include: 1
- Current anticoagulant or antiplatelet medications (15% of epistaxis patients are on long-term anticoagulation) 2
- History of hypertension (present in 33% of epistaxis patients) 2
- Personal or family history of bleeding disorders 1
- Prior nasal or sinus surgery 1
- Chronic kidney or liver disease 1
Stepwise Treatment Algorithm
Step 1: Initial Compression (First 10-15 Minutes)
Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway. 1 Apply firm, continuous pressure by pinching the soft lower third of the nose for 10-15 minutes without interruption or checking if bleeding has stopped. 1 This technique alone resolves the majority of nosebleeds. 1
During compression, assess hemodynamic stability including vital signs, mental status, and check for tachycardia, hypotension, orthostatic changes, or syncope—any of these indicate significant blood loss requiring hospital-level care. 1
Step 2: Topical Vasoconstrictors (If Bleeding Persists After 15 Minutes)
If bleeding continues after 15 minutes of continuous pressure, apply topical vasoconstrictors such as oxymetazoline or phenylephrine (2 sprays in the bleeding nostril). 1 This achieves hemorrhage control in 65-75% of cases that don't respond to compression alone. 1, 3 Follow with continued compression for an additional 5 minutes. 1
Step 3: Identify Bleeding Site and Cauterize
After removing any blood clots, perform anterior rhinoscopy to identify the bleeding site. 1 For identified anterior bleeding sites, use chemical cautery or electrocautery after proper anesthetization with topical lidocaine or tetracaine. 1 Electrocautery is more effective than chemical cauterization (silver nitrate), with recurrence rates of 14.5% versus 35.1%. 4 Avoid bilateral septal cautery to prevent septal perforation. 1
Step 4: Nasal Packing (If Bleeding Persists)
For elderly patients, especially those on anticoagulants or antiplatelet medications, nasal packing with resorbable materials is recommended. 1 Resorbable packing materials (Nasopore, Surgicel, Floseal) should be used as first choice. 1 These newer hemostatic materials are more effective and have fewer complications than traditional non-absorbable packing. 4
A critical point: anticoagulation or antiplatelet medications should NOT be discontinued in the absence of life-threatening bleeding. 1 For patients on warfarin with severe refractory bleeding, check INR and consider specialty consultation for potential reversal agents only if bleeding is life-threatening. 1
Step 5: Advanced Interventions (For Refractory Cases)
For nosebleeds refractory to initial local measures, intensive management options include: 2
- Endoscopic sphenopalatine artery ligation (97% success rate versus 62% for conventional packing) 4
- Endovascular embolization (80% success rate, comparable efficacy to surgical methods) 2, 4
Both surgical ligation and embolization procedures achieve >90% success for acute control of nasal bleeding. 2 However, embolization results in 232.1% greater hospital charges compared to ligation with no difference in outcomes or mortality in elderly patients. 5
Critical Management Pitfalls to Avoid
Do NOT aggressively lower blood pressure acutely during active epistaxis. 1 Routine acute blood pressure lowering is not recommended, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension. 1 Blood pressure should be monitored, but decisions about control must be based on bleeding severity, inability to control bleeding, individual comorbidities, and risks of blood pressure reduction. 1
Prevention and Follow-Up
Educate patients on preventive measures including: 1
- Application of petroleum jelly or other moisturizing agents to the anterior nasal septum 1
- Regular use of saline nasal sprays to keep nasal mucosa moist 1
- Use of humidifiers in dry environments 1
Document outcome within 30 days or document transition of care. 1 For patients with nasal packing, provide education about post-procedure care and warning signs requiring prompt reassessment. 1
When to Transfer to Emergency Department
Transfer to emergency department is indicated for: 1
- Bleeding duration >30 minutes despite proper compression and vasoconstrictors 1
- Signs of hemodynamic instability (dizziness, weakness, lightheadedness) 1
- Suspected posterior epistaxis requiring endoscopy or advanced interventions 1
- Inability to identify or control bleeding site in outpatient setting 1
Nonpacking interventions (cauterization, embolization, ligation) in elderly patients are associated with 9.9% increase in length of stay and 54.0% increase in hospital charges compared to nasal packing alone, but show no significant differences in morbidity or mortality. 5