What is the cause of epistaxis (nosebleed)?

From the Guidelines

For most cases of epistaxis, the initial management should involve sitting upright, leaning slightly forward, and pinching the soft part of the nose firmly for 10 to 15 minutes continuously without releasing pressure or checking if bleeding has stopped, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. This approach is based on the most recent and highest quality evidence available, which emphasizes the importance of prompt and effective first aid measures in managing epistaxis. The guidelines suggest that if bleeding does not stop after 15 minutes of continuous manual pressure, or if the individual becomes lightheaded from epistaxis, they should seek medical attention 1.

Some key points to consider in the management of epistaxis include:

• Applying an ice pack or cold compress to the bridge of the nose may help constrict blood vessels, although the usefulness of cryotherapy in the first aid setting is unknown 1.
• Avoiding picking, blowing, or inserting anything into the nose for 24 hours after bleeding stops to prevent further irritation and potential recurrence.
• For persistent bleeding, nasal decongestant sprays like oxymetazoline (Afrin) can be applied to help constrict blood vessels, but should not be used for more than 3 days to avoid rebound congestion.
• Petroleum jelly can be applied inside the nostrils twice daily for a week to prevent recurrence due to dryness.

It is also important to note that certain individuals, such as those taking anticoagulant or antiplatelet medication, or who have a blood-clotting disorder, should seek care from a healthcare professional unless bleeding has stopped 1. Additionally, if epistaxis occurs due to trauma, individuals should seek medical attention if they experience signs of brain injury, obvious nasal deformity, or signs of facial fracture 1.

Overall, the management of epistaxis should prioritize simple and effective first aid measures, with prompt medical attention sought if bleeding persists or is accompanied by other concerning symptoms.

From the Research

Definition and Treatment of Epistaxis

• Epistaxis refers to bleeding from the nostrils, nasal cavity, or nasopharynx 2
• Treatment options for epistaxis include first aid measures, topical agents, electrocautery, chemical cauterization, nasal packing, and endoscopic methods 2, 3

First Aid Measures and Topical Agents

• First aid measures such as external pressure and ice packing can be effective in stopping epistaxis 2
• Topical agents like oxymetazoline can stop 65-75% of nosebleeds in emergency settings 2
• Oxymetazoline has been shown to be effective in managing epistaxis, with 65% of patients successfully managed with oxymetazoline as their sole therapy 4

Nasal Packing and Endoscopic Methods

• Nasal packing can be applied using non-absorbable or absorbable materials, with newer hemostatic materials being more effective and having fewer complications 2
• Endoscopic ligation of arteries and endoscopic cauterization are more effective than conventional nasal packing and can be used to treat epistaxis 2
• Endoscopic methods have advantages over traditional methods, with higher success rates and fewer complications 2

Use of Tranexamic Acid

• Tranexamic acid has been investigated as a potential treatment for epistaxis, with some studies showing its effectiveness in promoting hemostasis 2, 5, 6
• However, a randomized controlled trial found that topical tranexamic acid was no more effective than placebo in controlling bleeding and reducing the need for anterior nasal packing 5
• A systematic review and meta-analysis found that topical tranexamic acid was associated with better bleeding cessation rates after treatment compared to standard practices 6

Management of Epistaxis

• Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency 3
• Compressive therapy is the first step to controlling anterior epistaxis, with adjuncts like oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 3
• Directive nasal cautery and topical therapy can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 3