Acute Management of HHT Epistaxis
For acute HHT epistaxis, apply direct nasal compression first, then use topical antifibrinolytics or gelatin sponge soaked in adrenaline, avoiding nasal packing and electrocautery which cause further vascular trauma. 1
Immediate Hemorrhage Control
First-Line Acute Measures
- Apply direct compression to the nose as the initial step to control active bleeding 1
- Use topical antifibrinolytics applied directly to bleeding sites for hemostasis 1
- Apply gelatin sponge soaked in adrenaline to bleeding telangiectasias 1
- Consider fibrin sealant spray for localized bleeding control 1
What to Avoid in Acute Settings
- Do not use traditional nasal packing as it causes additional trauma to fragile telangiectatic vessels and worsens subsequent bleeding 1
- Avoid electrocauterization during acute episodes as it damages surrounding vascular tissue and promotes more telangiectasia formation 1
Severe Acute Hemorrhage Protocol
When Simple Measures Fail
- For heavy acute epistaxis unresponsive to compression and topical measures, use an epistaxis balloon combined with artery ligation and/or embolization as the most effective treatment 1
- Laser therapy (argon, Nd:YAG, KTP/532, or diode—not CO2) can be used during acute episodes if equipment and expertise are available 1
- Argon plasma coagulation therapy provides effective acute hemostasis 1
Transition to Ongoing Management
After Acute Control
- Once acute bleeding is controlled, immediately initiate nasal moisturization with saline gels and humidification to prevent recurrent episodes 2
- Consider starting oral tranexamic acid (500 mg twice daily, gradually increasing to 1000 mg four times daily) for patients with recurrent episodes, unless contraindicated by recent thrombosis 3
Key Clinical Pitfall
The most common error in acute HHT epistaxis management is using aggressive nasal packing and cautery—the same techniques effective for non-HHT epistaxis—which paradoxically worsen outcomes by traumatizing the abnormal vasculature and accelerating telangiectasia formation 1. The principle is "do as little as possible for as long as possible" while achieving hemostasis 1.