What is the initial management and treatment for epistaxis (nosebleed)?

Initial Management and Treatment for Epistaxis

Apply firm, sustained compression to the lower third of the nose for at least 5 minutes as the immediate first-line treatment for any nosebleed. 1, 2

Immediate First-Line Management

Patient Positioning and Compression Technique

• Position the patient sitting upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or being swallowed 2, 3
• Apply firm, continuous digital pressure by pinching the soft lower third of the nose for a minimum of 5-10 minutes without interruption 1, 2
• Critical pitfall: Do not check if bleeding has stopped before 5 minutes—this is the most common reason for treatment failure 3
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 2, 3

Initial Assessment During Compression

• Distinguish patients requiring prompt management based on bleeding severity, airway compromise risk, and hemodynamic stability 1, 4
• Document risk factors: personal/family history of bleeding disorders, anticoagulant/antiplatelet medications, intranasal drug use 1, 4

Second-Line Treatment (If Bleeding Persists After 5+ Minutes)

Topical Vasoconstrictors

• Apply oxymetazoline or phenylephrine (2 sprays in the bleeding nostril) after clearing blood clots, which resolves 65-75% of nosebleeds that don't respond to compression alone 2, 4, 5
• Alternative: Cotton pledgets soaked in oxymetazoline or epinephrine 1:1,000 can be applied directly to the bleeding site 6

Emerging Evidence for Tranexamic Acid

• Topical tranexamic acid promotes hemostasis in 78% of patients versus 35% with oxymetazoline, with faster bleeding control (within 10 minutes in most cases) and fewer rebleeds 5, 7
• This represents a newer, cost-effective option readily available in emergency settings 7

Third-Line Treatment (If Bleeding Still Persists)

Nasal Cautery

• Perform anterior rhinoscopy after removing blood clots to identify the bleeding site 4, 5
• Electrocautery is preferable to chemical cautery (silver nitrate) with lower recurrence rates (14.5% vs 35.1%) and less pain 2, 5
• Anesthetize the bleeding site with topical lidocaine or tetracaine before cauterization 3
• Restrict cautery only to the active bleeding site to minimize risk of septal perforation—never cauterize both sides of the septum simultaneously 3

Nasal Packing (If Cautery Fails or Bleeding Site Not Visualized)

• Use resorbable materials (Nasopore, gelatin sponge, Surgicel, Floseal) in patients with bleeding disorders or on anticoagulants 3, 5
• Non-resorbable options include petroleum jelly gauze, PVA tampons (Merocel), or balloon devices (Rapid-Rhino) 5, 8
• Newer hemostatic materials (thrombin matrix, fibrin glue) are more effective with fewer complications than traditional packing 5

Prevention of Recurrence

• Apply petroleum jelly or other moisturizing agents to the anterior nasal septum regularly 2, 4
• Use saline nasal sprays to keep nasal mucosa moist 2, 3
• Consider humidifier use in dry environments 3
• Instruct patients to avoid nose picking or rubbing to allow healing 3

Advanced Management for Refractory Cases

When to Perform Nasal Endoscopy

• Perform when bleeding is difficult to control, there is concern for unrecognized pathology, or patient has recurrent bleeding despite prior treatment 4
• Assess for nasal/oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history suggesting hereditary hemorrhagic telangiectasia 4

Surgical and Interventional Options

• Endoscopic sphenopalatine artery ligation is more effective than conventional packing (97% vs 62% success) 5
• Arterial embolization using gelatin sponge, foam, PVA or coils achieves 80% success rate for intractable cases 5
• These interventions require otolaryngology referral 8, 6

Special Considerations

Anticoagulated Patients

• Initiate first-line treatments (compression, vasoconstrictors) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications 4

Posterior Epistaxis

• More likely to require hospitalization and twice as likely to need nasal packing compared to anterior epistaxis 6
• More common in elderly patients with hypertension, atherosclerosis, or clotting disorders 9
• Posterior packing carries risk of aspiration if dislodged and often requires hospital admission with otolaryngology consultation 6

Pediatric Considerations

• Epistaxis typically originates from anterior septum (Kiesselbach's plexus) in children 2
• Only 6.9% of pediatric cases require procedures beyond compression and topical agents 2
• Mean age of presentation is 7.5 years, with 57% being male 2

When to Seek Emergency Care or Specialist Referral

• Bleeding does not stop after 15 minutes of continuous proper compression 2
• Patient experiences dizziness, weakness, or lightheadedness suggesting significant blood loss 2
• Posterior bleeding suspected or confirmed 6
• Significant comorbid conditions or complications of blood loss present 8
• Bleeding refractory to packing or cauterization 4, 8