What is the management of epistaxis?

Epistaxis Management

For active epistaxis, immediately apply firm sustained compression to the lower third of the nose for at least 5-10 minutes with the patient sitting upright and head tilted slightly forward—this single intervention resolves the vast majority of nosebleeds and should be your first-line treatment. 1, 2

Immediate Initial Management

Patient Positioning and First-Line Intervention

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or stomach 2, 3
• Apply firm sustained compression to the soft lower third of the nose for 5-10 minutes minimum without checking if bleeding has stopped during this time 1, 4, 2
• Instruct the patient to breathe through their mouth and spit out blood rather than swallowing it 4, 2
• This compression alone is sufficient in the vast majority of epistaxis cases 1, 4

Common pitfall: Insufficient compression time—many patients check too early, which disrupts clot formation. Maintain pressure for the full duration without interruption 4, 3

If Bleeding Persists After Initial Compression

Topical Vasoconstrictors

• Clear any clots from the nasal cavity first, then apply a topical vasoconstrictor such as oxymetazoline or phenylephrine 4, 2
• Spray 2 times in the bleeding nostril and continue compression for an additional 5 minutes 4
• This approach resolves 65-75% of epistaxis cases presenting to emergency departments 4, 5

Identify and Treat the Bleeding Site

• Perform anterior rhinoscopy using a nasal speculum and good light source (headlamp preferred) to identify the specific bleeding site 3, 6
• For identified anterior bleeding sites, use chemical cautery with silver nitrate after proper anesthetization, which is more effective than compression alone and has fewer recurrences (14.5% vs 35.1%) 5, 6
• Apply moisturizing or lubricating agents (petroleum jelly) to the cauterized area to prevent recurrence 1, 2, 3

Nasal Packing (If Above Measures Fail)

Packing Material Selection

• Use resorbable packing materials for patients on anticoagulants or antiplatelet medications 1, 4, 3
• Options include absorbable materials (Nasopore nasal tampon), hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan), or fibrin glue—these newer agents have advantages over traditional non-absorbable packing 5
• For patients not on anticoagulation, non-absorbable materials like petroleum jelly gauze, BIPP gauze, or PVA tampons (Merocel) may be used 5

Patient Education for Packing

• Educate the patient about the type of packing placed, timing and plan for removal (if not resorbable), post-procedure care, and warning signs requiring prompt reassessment 1

Special Considerations for Anticoagulated Patients

Critical principle: In the absence of life-threatening bleeding, initiate first-line treatments (compression, vasoconstrictors, cautery, packing) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications 1, 4, 3

When to Escalate Care

Indications for ENT Referral or Advanced Treatment

• Bleeding persists after 15 minutes of continuous pressure 4, 3
• Bleeding duration exceeds 30 minutes over a 24-hour period 4
• Patient shows signs of hemodynamic instability (tachycardia, hypotension) or dizziness from blood loss 4
• Persistent or recurrent bleeding not controlled by packing or cauterization 1, 3

Advanced Interventions

• Perform nasal endoscopy to examine the nasal cavity and nasopharynx for unrecognized pathology or difficult-to-control bleeding 3, 5
• Consider surgical arterial ligation (especially sphenopalatine artery), which is more effective than conventional nasal packing (97% vs 62%) 5
• Endoscopic cauterization is more effective than ligation for identified bleeding sites 5
• For intractable cases, endovascular embolization achieves 80% success rate with comparable efficacy to surgical methods 5

Prevention and Long-Term Management

Preventive Measures

• Apply petroleum jelly or nasal emollients regularly to prevent mucosal dryness 4, 2, 3
• Use saline nasal sprays to keep nasal mucosa moist 4, 2
• Recommend humidifiers, especially in dry environments 4

Documentation and Risk Assessment

• Document factors increasing bleeding frequency or severity: personal/family history of bleeding disorders, anticoagulant/antiplatelet use, or intranasal drug use 1, 3
• Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds (concern for hereditary hemorrhagic telangiectasia) 1, 3
• Document outcome of intervention within 30 days or document transition of care 1, 3

Patient Education

• Educate patients and caregivers about home treatment techniques, preventive measures, and indications to seek additional medical care 1, 3