What are the management options for epistaxis?

Epistaxis Management

Initial First Aid Measures

For acute epistaxis, seat the patient upright with head tilted slightly forward and apply firm, continuous compression to the soft lower third of the nose for a full 10-15 minutes without interruption—this single intervention resolves the majority of cases. 1

• The patient must breathe through their mouth and spit out blood rather than swallowing it to prevent nausea and vomiting 1
• Critical pitfall: Do not tilt the head backward, as this causes blood to flow into the throat and does not help control bleeding 2
• Critical pitfall: Compression must be maintained for the full 10-15 minutes without checking if bleeding has stopped—insufficient compression time is a common cause of treatment failure 3, 2
• Compression alone is sufficient in the vast majority of epistaxis cases 1, 3

If Bleeding Persists After Initial Compression

If bleeding continues after 15 minutes of proper compression, clear the nasal cavity of clots and apply a topical vasoconstrictor (oxymetazoline or phenylephrine spray—2 sprays in the bleeding nostril), then continue compression for another 5 minutes. 1, 2

• Vasoconstrictor application stops bleeding in 65-75% of cases treated in the emergency department 4, 5
• Over-the-counter options include oxymetazoline (Afrin) or phenylephrine 4
• Be aware that vasoconstrictors may be associated with increased risk of cardiac or systemic complications in susceptible patients 4

After Bleeding Control: Prevention of Recurrence

Once bleeding has stopped, apply moisturizing or lubricating agents (such as petroleum jelly) to the nasal mucosa and recommend regular use of saline nasal sprays to prevent recurrence. 1, 3

• Keeping the nose moist with nasal saline and humidifier use helps prevent future nosebleeds 4
• Patients should avoid picking or rubbing the nose to allow healing 4

Advanced Treatment for Refractory Bleeding

If bleeding does not stop after 15 minutes of continuous pressure with vasoconstrictors, proceed to nasal packing. 1

Nasal Packing Options:

• For patients on anticoagulants or antiplatelet medications: Use absorbable tamponade material (such as Nasopore, Surgicel, Floseal, or Spongostan) 1, 2, 5
• Non-absorbable options include petroleum jelly gauze, BIPP gauze, PVA nasal tampons (Merocel), or balloon devices (Rapid-Rhino) 5
• Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) are more effective with fewer complications than traditional packing 5

Nasal Cautery:

When an anterior bleeding site is identified, cautery (chemical or electrical) can be performed under local anesthesia, with electrocautery being more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%). 4, 5

• Cautery may be painful despite anesthesia and can damage the nasal lining if performed too vigorously 4
• Young children and uncooperative patients may require sedation or general anesthesia 4

Role of Nasal Endoscopy

Nasal endoscopy should be performed in the evaluation of patients with epistaxis, as it can localize the bleeding site in 87-93% of cases. 4

• Posterior epistaxis can occur from the septum (70%) or lateral nasal wall (24%), making targeted therapy difficult without endoscopic identification 4
• The decision to proceed with endoscopy in less severe nosebleeds should involve shared decision-making, weighing benefits against risks 4

Surgical Management for Intractable Cases

For severe or recurrent epistaxis unresponsive to conservative measures, endoscopic sphenopalatine artery ligation is highly effective (97% success rate) compared to conventional nasal packing (62%). 5, 6

• Endoscopic cauterization is more effective than ligation alone 5
• Anterior ethmoid artery ligation may be needed for intractable anterior epistaxis once identified as the primary source 6
• Arterial embolization using gelatin sponge, foam, PVA, or coils achieves 80% success rate with comparable efficacy to surgical methods 5
• Recurrence rates vary: <10% for surgical artery ligation or embolization versus 50% for nasal packing 4

Critical Management Principles for Patients on Anticoagulants

For patients on anticoagulants, initiate first-line local control measures (compression, vasoconstrictors, packing) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications, unless bleeding is life-threatening. 3, 2

• Do not withhold anticoagulation for non-life-threatening epistaxis 2
• Antifibrinolytic agents (tranexamic acid) or desmopressin may support hemostasis without reversing anticoagulation 2
• Tranexamic acid promotes hemostasis in 78% of patients versus 35% with oxymetazoline and 31% with nasal packing 5
• Reversal agents should only be used for life-threatening bleeding due to significant thrombotic risk 2

When to Seek Emergency Care

Patients should seek immediate medical attention if:

• Bleeding does not stop after 15 minutes of continuous pressure 1, 3
• Signs of hemodynamic instability (tachycardia, hypotension, dizziness, lightheadedness, weakness from blood loss) develop 3, 2
• Severe bleeding (duration >30 minutes over a 24-hour period) occurs 3

Follow-Up and Outcome Documentation

Routine follow-up is recommended for patients who have undergone invasive treatments for epistaxis to assess for complications and recurrent bleeding. 4

• Patients should be educated about secondary symptoms requiring additional follow-up: persistent nasal blockage, pain, severe crusting 4
• Adequate follow-up allows assessment for underlying conditions (primary bleeding disorders, hematologic malignancies, intranasal tumors, vascular malformations) when treatments are ineffective or bleeding recurs 4
• Document outcomes within 30 days to improve individual patient care and provide research opportunities 4