From the Guidelines
The most effective initial management of epistaxis involves having the person sit down and continuously hold the lower third or soft portion of the nose pinched closed for 10 to 15 minutes while leaning slightly forward, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. This approach is supported by the highest quality and most recent evidence, which emphasizes the importance of direct pressure in managing epistaxis. The guidelines suggest that a person experiencing epistaxis should sit with their head slightly forward with their nostrils pinched for 10 to 15 minutes, and if the bleeding does not stop after 15 minutes of continuous manual pressure, or if they become lightheaded, they should seek medical attention 1.
Some key points to consider in the management of epistaxis include:
- Applying direct pressure to the soft part of the nose for 10 to 15 minutes while leaning slightly forward
- Avoiding nose picking, strenuous activity, hot showers, and blood thinners for several days after a nosebleed
- Addressing underlying causes like hypertension, blood disorders, or medication effects
- Considering topical vasoconstrictors, nasal cautery, or nasal packing for persistent bleeding
- Using daily saline nasal spray and humidification to prevent mucosal drying in cases of recurrent epistaxis
It is essential to note that the management of epistaxis may vary depending on the underlying cause and the severity of the bleeding. However, the initial approach of applying direct pressure and leaning slightly forward is a crucial step in managing epistaxis, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. Additionally, the use of topical vasoconstrictors, such as oxymetazoline, may be beneficial in some cases, as suggested by the clinical practice guideline on nosebleed (epistaxis) published in 2020 1.
From the Research
Epistaxis Management Overview
Epistaxis, or bleeding from the nostrils, nasal cavity, or nasopharynx, can be managed through various methods, including first aid measures, topical agents, and more invasive procedures 2. The choice of management depends on the severity of the bleeding, the patient's history, and the available resources.
First Aid Measures
First aid measures for epistaxis include external pressure and ice packing, which can stop 65-75% of nosebleeds in the emergency department 2. Compressive therapy is also a first step in controlling anterior epistaxis, and can be used in conjunction with oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 3.
Topical Agents and Cauterization
Topical agents such as oxymetazoline and tranexamic acid can be used to promote hemostasis in patients with epistaxis 2, 4. Directive nasal cautery using silver nitrate can also be used to control localized bleeding or prominent vessels 3. However, a study found that topical intranasal tranexamic acid was no more effective than placebo in reducing the need for anterior nasal packing in patients with spontaneous epistaxis 4.
Nasal Packing and Endoscopic Methods
Nasal packing can be applied using non-absorbable or absorbable materials, and newer hemostatic materials such as hemostatic gauzes and fibrin glue can be more effective and have fewer complications 2. Endoscopic ligation of arteries, mainly the sphenopalatine artery (SPA), can also be used to manage epistaxis, and is more effective than conventional nasal packing 2. Endoscopic cauterization is another option, and is more effective than ligation 2.
Embolization and Other Methods
Embolization using gelatin sponge, foam, PVA, and coils can be used to manage intractable epistaxis, with a success rate of 80% and comparable efficacy and complications to surgical methods 2. Other methods, such as the use of topical therapy and nasal packing, can also be used if other methods are unsuccessful 3.
Key Considerations
Key considerations in the management of epistaxis include the level of severity, the patient's history, and the available resources 5. Education regarding the basic principles of first aid for epistaxis is also important, as knowledge of epistaxis management is often poor 6.
Management Options
Some management options for epistaxis include:
- First aid measures such as external pressure and ice packing
- Topical agents such as oxymetazoline and tranexamic acid
- Nasal packing using non-absorbable or absorbable materials
- Endoscopic ligation of arteries, mainly the sphenopalatine artery (SPA)
- Endoscopic cauterization
- Embolization using gelatin sponge, foam, PVA, and coils
- Topical therapy and nasal packing if other methods are unsuccessful 2, 3, 4, 5, 6