What is the initial treatment for epistaxis (nosebleed) in a 74-year-old female patient not on anticoagulation (blood thinner) treatment?

Initial Treatment for Epistaxis in a 74-Year-Old Female Not on Anticoagulation

Begin immediately with firm, sustained digital compression to the soft lower third of the nose for a minimum of 5 minutes without interruption, with the patient sitting upright and head tilted slightly forward. 1, 2

Immediate First-Line Management

Patient Positioning and Compression Technique

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed 1, 2
• Apply firm, continuous compression to the soft lower third of the nose (not the nasal bridge) for a full 5-10 minutes without checking if bleeding has stopped 1, 2
• Have the patient breathe through her mouth and spit out any blood rather than swallowing it 2
• Do not release pressure prematurely—this is the most common pitfall that leads to treatment failure, as it prevents clot formation 2, 3

Critical Assessment During Initial Management

Given this patient's age (74 years), she is at dramatically increased risk for severe epistaxis and posterior bleeding sources that are more difficult to control 2. During compression, assess for:

• Signs of hemodynamic instability: tachycardia, hypotension, pallor, dizziness, or orthostatic changes 2
• Any of these findings indicate significant blood loss requiring emergency department evaluation 2

If Bleeding Persists After 5-10 Minutes of Compression

Topical Vasoconstrictors

• Apply oxymetazoline or phenylephrine spray directly to the bleeding site after clearing any blood clots 1, 2
• This achieves hemorrhage control in 65-75% of cases that don't respond to compression alone 2, 4

Identify the Bleeding Site

• Perform anterior rhinoscopy after removing any blood clots to identify the source of bleeding 1
• This is essential before proceeding to definitive treatment 1, 2

Definitive Treatment Based on Bleeding Site

If a Specific Bleeding Site is Identified

• Nasal cautery is the preferred definitive treatment after anesthetizing the area with topical lidocaine or tetracaine 1, 2
• Restrict cautery application only to the active or suspected bleeding site(s) to minimize risk of septal perforation 1, 2
• Electrocautery is more effective than chemical cauterization (silver nitrate), with recurrence rates of 14.5% versus 35.1% 4
• Avoid bilateral septal cautery to prevent septal perforation 2

If Bleeding Site Cannot Be Identified or Bleeding Persists

• Proceed to nasal packing if bleeding continues despite compression and vasoconstrictors 1
• Use resorbable packing materials (Nasopore, Surgicel, Floseal) as first choice 1, 2
• Since this patient is not on anticoagulation, standard packing materials are appropriate, though resorbable materials have fewer complications 1, 4

Post-Treatment Management

Prevention of Recurrence

• Apply petroleum jelly or other moisturizing agents to the nasal mucosa 1, 2
• Prescribe regular saline nasal sprays to maintain mucosal moisture 2
• Educate the patient to avoid nasal trauma, nose-picking, and forceful nose-blowing 1, 2

Documentation and Follow-Up

• Document risk factors including: prior nasal/sinus surgery, nasal oxygen or CPAP use, intranasal medications, personal or family history of bleeding disorders, chronic kidney or liver disease 2
• Arrange follow-up within 30 days to assess outcome 1

When to Transfer to Emergency Department

This 74-year-old patient should be transferred to the emergency department if: 2

• Bleeding duration exceeds 30 minutes (meets threshold for "severe epistaxis") 1, 2
• Signs of hemodynamic instability develop (tachycardia, hypotension, dizziness) 2
• Bleeding persists despite compression, vasoconstrictors, and initial packing attempts 2
• Elderly patients with hypertension are at high risk for posterior sources requiring endoscopic evaluation 2

Critical Pitfalls to Avoid

• Do not have the patient tilt her head backward—this causes blood to flow into the airway and stomach 2, 3
• Do not compress the nasal bridge—compression must be applied to the soft lower third where bleeding vessels are located 2, 3
• Do not check if bleeding has stopped before 5-10 minutes—premature release prevents clot formation 2, 3
• Do not aggressively lower blood pressure acutely if hypertension is present, as this can cause end-organ ischemia in elderly patients with chronic hypertension 2

Special Considerations for This Age Group

• Advanced age dramatically increases epistaxis severity and complications 2
• This patient has significantly higher rates of posterior epistaxis which is more difficult to control and carries greater morbidity 2
• Consider nasal endoscopy if bleeding is difficult to control or recurrent, as elderly patients may have unrecognized pathology 1
• Assess for hereditary hemorrhagic telangiectasia (HHT) if there is history of recurrent bilateral nosebleeds or family history of recurrent nosebleeds 1