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 the first-line treatment before any other intervention. 1

Immediate Management Algorithm

Step 1: Initial Assessment and Positioning

• Triage for severity: Distinguish patients requiring prompt management (bleeding >30 minutes in 24 hours, hemodynamic instability, bilateral bleeding, bleeding from mouth, history of hospitalization for epistaxis) from those who do not 1
• Position the patient: Sit upright with head tilted slightly forward to prevent blood from entering the airway or stomach 2, 3
• Instruct patient to breathe through mouth and spit out blood rather than swallowing it 2, 3

Step 2: Nasal Compression (First-Line Treatment)

• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 1, 3
• This can be performed by the patient, caregiver, or clinician 1
• Critical pitfall: Insufficient compression time (checking too early) is the most common cause of treatment failure 2, 4
• Compression alone resolves the vast majority of anterior epistaxis cases 1, 3

Step 3: Topical Vasoconstrictors (If Compression Fails)

• If bleeding persists after 15 minutes of compression: Clear clots from the nasal cavity, then apply topical vasoconstrictor 1, 3
• Preferred agents: Oxymetazoline or phenylephrine spray—apply 2 sprays in the bleeding nostril 2, 3, 5
• Continue compression for an additional 5 minutes after vasoconstrictor application 2
• Effectiveness: Vasoconstrictors stop bleeding in 65-75% of emergency department cases 3, 6
• Caution: May increase risk of cardiac or systemic complications in susceptible patients 3

Step 4: Identify and Treat Bleeding Site

• If a specific bleeding site is identified: Use nasal cautery (chemical or electrocautery) 1
• Electrocautery is superior to chemical cauterization: 14.5% recurrence rate versus 35.1% with silver nitrate 3, 6
• Apply moisturizing or lubricating agents (petroleum jelly) after cautery to prevent recurrence 1, 2, 3

Step 5: Advanced Interventions (If Above Measures Fail)

Topical Tranexamic Acid

• Highly effective alternative to traditional packing: Topical application of injectable tranexamic acid (500 mg in 5 mL) stops bleeding within 10 minutes in 71% of patients versus 31% with nasal packing 7
• Moderate-quality evidence supports topical tranexamic acid as probably better than other topical agents in stopping bleeding within the first 10 minutes 8
• Significantly shorter hospital stays and higher patient satisfaction compared to nasal packing 8, 7

Nasal Packing

• Indications: Failure of compression, vasoconstrictors, and cautery; life-threatening bleeding; posterior bleeding source 1
• For patients on anticoagulants: Use resorbable packing materials 2, 3, 4
• Options include: Non-absorbable materials (petroleum jelly gauze, PVA tampons/Merocel, balloons/Rapid-Rhino) or absorbable materials (Nasopore, hemostatic gauzes/Surgicel, thrombin matrix/Floseal, gelatin sponge/Spongostan, fibrin glue) 6
• Recurrence rate: Approximately 50% with nasal packing alone 3

Special Populations

Patients on Anticoagulants/Antiplatelets

• Do NOT withhold, reverse anticoagulation, or transfuse for non-life-threatening epistaxis 2, 4
• First-line local control measures (compression, vasoconstrictors) should always be attempted first 4
• Only consider reversal agents (4-factor prothrombin complex concentrate) for life-threatening bleeding due to significant thrombotic risk 4
• Antifibrinolytic agents (tranexamic acid) or desmopressin may support hemostasis without reversing anticoagulation 4
• Use resorbable packing if packing is required 2, 3, 4

Oral Tranexamic Acid for Recurrent Epistaxis

• Moderate-quality evidence shows oral tranexamic acid given regularly over several days reduces re-bleeding risk from 69% to 49% within 10 days (RR 0.73) 8
• Consider for patients with recurrent episodes 8

Prevention of Recurrence

• Apply petroleum jelly or lubricating agents to nasal mucosa once bleeding stops 1, 2, 3, 4
• Use saline nasal sprays regularly to keep nasal passages moist 2, 3, 4
• Humidifier use in dry environments 2, 4
• Avoid nose picking or rubbing to allow healing 3

When to Refer or Escalate Care

Immediate Emergency Department Referral

• Bleeding not controlled after 15 minutes of continuous pressure 2, 4
• Signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension) 1, 4
• Dizziness or weakness from blood loss 2, 4
• Bilateral bleeding or bleeding from mouth suggesting posterior source 1

ENT Referral for Advanced Management

• Endoscopic evaluation: Localizes bleeding site in 87-93% of cases 3
• Endoscopic sphenopalatine artery ligation: 97% success rate versus 62% with conventional packing 6
• Endoscopic cauterization: More effective than arterial ligation 6
• Embolization for intractable cases: 80% success rate with comparable efficacy to surgical methods; recurrence rate <10% 3, 6

Documentation Requirements

• Document factors increasing bleeding frequency or severity: personal/family history of bleeding disorders, anticoagulant/antiplatelet use, intranasal drug use 1
• Follow-up within 30 days for patients requiring invasive treatments to assess complications and recurrent bleeding 3