How to manage a patient with epistaxis and hypertension, presenting with a blood pressure of 160/100 mmHg?

Management of Epistaxis with Hypertension (BP 160/100 mmHg)

The patient should receive immediate local control of epistaxis with continuous nasal pinching for 10-15 minutes while seated with head forward, followed by blood pressure monitoring and reassessment, but does not require emergency antihypertensive treatment at this BP level. 1

Immediate Epistaxis Management

First, control the bleeding using standard first aid measures:

• Have the patient sit upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or stomach 1
• Apply continuous manual pressure to the soft lower third of the nose for 10-15 minutes without interruption 1
• Instruct the patient to breathe through their mouth and spit out any blood 1
• If bleeding persists after 15 minutes of continuous pressure, or if the patient becomes lightheaded, seek immediate medical attention 1

Consider nasal packing if simple pressure fails:

• Patients with hypertension experiencing epistaxis are more likely to require posterior nasal packing (odds ratio 4.58) and emergency department visits compared to normotensive patients 2
• Anterior nasal packing may be sufficient for most cases, but be prepared for more aggressive intervention 2

Blood Pressure Assessment and Management

The BP of 160/100 mmHg does NOT constitute a hypertensive emergency and should not be treated acutely in this setting:

• This BP level is below the threshold of 180/110 mmHg that would warrant immediate treatment consideration 1
• The relationship between epistaxis and hypertension is controversial - elevated BP during epistaxis may represent stress response or "white coat" phenomenon rather than causation 1, 3
• However, systolic BP >180 mmHg is independently associated with persistent epistaxis (odds ratio 1.03 per mmHg increase) 4

Important caveat: While the elevated BP may contribute to persistent bleeding, acutely lowering BP during active epistaxis is not recommended unless BP exceeds 180/110 mmHg 1

Assessment for Antiplatelet/Anticoagulant Use

Screen for medications that may prolong bleeding:

• Patients on anticoagulant or antiplatelet medications should seek medical attention unless bleeding has completely stopped 1
• If the patient is on dual antiplatelet therapy (DAPT) or anticoagulation, consider discontinuing one agent if bleeding persists despite local measures 1
• The decision to discontinue anticoagulation must weigh bleeding risk against thrombotic risk 1

Disposition and Follow-Up

For this specific patient with BP 160/100 mmHg:

• If epistaxis resolves with local measures: The patient can be managed as outpatient with primary care follow-up for hypertension management 1
• Inform the primary care physician about the elevated BP reading (>140/90 mmHg) for proper hypertension diagnosis and treatment 1
• The patient does not require emergency department admission solely for BP of 160/100 mmHg 1

If epistaxis persists beyond 15 minutes:

• Seek emergency medical attention for nasal packing and possible ENT consultation 1
• Patients with hypertension and epistaxis have increased risk of requiring emergency department care 2

Long-Term Hypertension Management

After acute episode resolution:

• Confirm hypertension diagnosis with ambulatory or home BP monitoring if BP remains ≥160/100 mmHg 1
• Initiate or optimize antihypertensive therapy through primary care 1
• Patients with hypertension have 1.47 times higher risk of epistaxis requiring hospital visits 2
• Medication noncompliance is a direct cause of both hypertensive urgency and epistaxis in some cases 5

Key Pitfalls to Avoid

• Do not aggressively lower BP acutely during active epistaxis unless it exceeds 180/110 mmHg - this may represent stress response 1
• Do not assume causation - while hypertension is associated with epistaxis, the elevated BP at presentation may be effect rather than cause 1, 3
• Do not delay local bleeding control to treat BP - epistaxis management takes priority 1
• Do not discharge without primary care follow-up for BP management, as this represents stage 2 hypertension requiring treatment 1