What is the treatment for epistaxis?

Epistaxis Treatment

For active epistaxis, immediately apply firm sustained compression to the lower third of the nose for at least 10-15 minutes without interruption—this single intervention stops the majority of nosebleeds and should be attempted before any other treatment. 1

Immediate First-Line Management

Patient Positioning and Compression Technique

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 2, 3
• Apply firm, continuous pressure to the soft lower third of the nose (not the nasal bridge) for a full 10-15 minutes without checking if bleeding has stopped 1, 3
• The patient should breathe through their mouth and spit out any blood rather than swallowing it 2, 3
• Compression alone resolves the vast majority of epistaxis cases 1, 3

Common pitfall: Insufficient compression time is the most frequent cause of treatment failure—patients often check too early, disrupting clot formation 2, 4

If Bleeding Persists After 15 Minutes

• Clear the nasal cavity of clots first 2, 3
• Apply a topical vasoconstrictor: oxymetazoline or phenylephrine spray (2 sprays in the bleeding nostril) 2, 3, 5
• Continue firm compression for another 5 minutes 2, 3
• Topical vasoconstrictors stop bleeding in 65-75% of emergency department cases 3, 6

Prevention of Recurrence

Once bleeding stops, immediate preventive measures are essential:

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 2, 3, 4
• Use saline nasal sprays regularly to keep nasal passages moist 2, 3, 4
• Consider using a humidifier, especially in dry environments 2, 3

Advanced Treatment Options (If Basic Measures Fail)

Nasal Cauterization

• Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) when an anterior bleeding site is identified 3, 6
• Requires identification of the specific bleeding site 1, 3

Topical Tranexamic Acid

• Topical tranexamic acid stops bleeding within 10 minutes in 70% of patients compared to 30% with other topical agents 7
• Promotes hemostasis in 78% of patients versus 35% with oxymetazoline alone 6
• Reduces re-bleeding risk from 67% to 47% within 10 days 7
• Can be used as an alternative to nasal packing in the emergency setting 8

Nasal Packing

• Indicated when compression and topical agents fail to control bleeding 3
• For patients on anticoagulants or antiplatelet medications, use absorbable packing materials 3, 4
• Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) are more effective with fewer complications than traditional packing 6

Special Considerations for Anticoagulated Patients

Critical principle: Do not withhold, reverse anticoagulation, or administer blood products for non-life-threatening epistaxis—always attempt first-line local control measures first 4

• Start with direct nasal compression and topical vasoconstrictors without stopping anticoagulation unless bleeding is life-threatening 4
• Antifibrinolytic agents (tranexamic acid) or desmopressin may support hemostasis without reversing anticoagulation 4
• Reversal agents should only be used for life-threatening bleeding due to significant thrombotic risk 4

Indications for Urgent/Emergency Evaluation

Patients require prompt management if they have: 1

• Bleeding duration >30 minutes over a 24-hour period 1, 2
• Bleeding from both nostrils or from the mouth 1
• Signs of acute hypovolemia (tachycardia, syncope, orthostatic hypotension) 1
• Dizziness or weakness from blood loss 2, 4
• History of hospitalization or blood transfusion for prior nosebleeds 1
• Bleeding that continues despite 15 minutes of continuous pressure 2, 4

Surgical Management for Refractory Cases

When medical management fails:

• Endoscopic sphenopalatine artery ligation is more effective than conventional nasal packing (97% vs 62% success rate) 6
• Endoscopic cauterization is more effective than arterial ligation 6
• Arterial embolization using gelatin sponge, foam, or coils has 80% success rate with comparable efficacy to surgical methods 6
• Recurrence rates: <10% for surgical ligation or embolization versus 50% for nasal packing alone 3

Documentation and Follow-Up

• Document factors that increase bleeding frequency or severity: personal or family history of bleeding disorders, anticoagulant/antiplatelet use, intranasal drug use 1
• Routine follow-up is recommended for patients who underwent invasive treatments to assess for complications and recurrent bleeding 3
• Assessment within 30 days allows evaluation for underlying conditions when treatments are ineffective 3