Initial Approach to Non-Traumatic Epistaxis
The first-line treatment for non-traumatic epistaxis is to have the patient sit upright with head tilted slightly forward and apply firm, continuous compression to the soft lower third of the nose for 10-15 minutes without interruption. 1, 2, 3
Immediate Patient Positioning and Initial Compression
Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed, which can cause nausea and obscure the amount of blood loss 2, 3
Apply firm, sustained pressure to the soft lower part of the nose (not the bony bridge) for a full 10-15 minutes without checking if bleeding has stopped 1, 2, 3
Instruct the patient to breathe through their mouth and spit out any blood rather than swallowing it 4, 2
Compression alone resolves the vast majority of epistaxis cases and should not be rushed or interrupted prematurely 1, 2
Common Pitfall to Avoid
The most frequent error is insufficient compression time—patients and providers often check for bleeding before the full 10-15 minutes, which disrupts clot formation and prolongs bleeding 4, 3
Second-Line Treatment: Topical Vasoconstrictors
If bleeding persists after adequate compression:
Clear the nasal cavity of clots first, then apply a topical vasoconstrictor such as oxymetazoline or phenylephrine spray 4, 2, 3
Spray 2 times into the bleeding nostril and continue compression for an additional 5 minutes 4
This approach stops bleeding in 65-75% of cases that don't respond to compression alone 4, 5, 6
Alternatively, cotton pledgets soaked in oxymetazoline or epinephrine 1:1,000 can be applied to the bleeding site 6
Cautery for Visible Bleeding Source
If a specific bleeding vessel is identified on the anterior septum (most commonly in Kiesselbach's plexus), chemical cautery with silver nitrate can be applied after adequate anesthesia and vasoconstriction 5, 6
Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) but requires appropriate equipment and training 5
Prevention of Recurrence
Once bleeding has stopped:
Apply petroleum jelly or other lubricating agents to the nasal mucosa to prevent recurrence from dryness 4, 2, 3
Recommend regular use of saline nasal sprays to maintain mucosal moisture 4, 2, 3
Consider using a humidifier, especially in dry environments 4
When to Escalate Care
Refer to emergency department or ENT specialist if:
Bleeding continues after 15 minutes of continuous proper compression 4, 3
Severe bleeding (duration >30 minutes over a 24-hour period) 4, 3
Signs of hemodynamic instability such as tachycardia, hypotension, or dizziness from blood loss 4, 3
Suspected posterior epistaxis (bleeding not visible on anterior rhinoscopy, more common in elderly patients) 1, 7
Advanced Treatment Options
For refractory cases:
Nasal packing with absorbable materials (Nasopore, Surgicel, Floseal) or non-absorbable materials (Merocel, Rapid-Rhino balloon) 5, 6
For patients on anticoagulants, use resorbable packing material to avoid the need for painful removal 4, 2
Topical tranexamic acid promotes hemostasis in 78% of patients versus 35% with oxymetazoline alone 5
Endoscopic evaluation, arterial ligation, or embolization for persistent or recurrent bleeding 2, 3
Special Considerations
Do not discontinue anticoagulants or antiplatelet medications for isolated epistaxis unless bleeding is life-threatening; initiate first-line treatments first 4
Avoid ice packs to the forehead, neck, or nose—the 2021 International Consensus on Resuscitation concluded that current evidence does not support cryotherapy as a first aid intervention for epistaxis 1
Most anterior epistaxis (>90% of cases) can be managed in the outpatient setting, while posterior epistaxis often requires hospitalization and specialist consultation 1, 6, 7