What are the management options for epistaxis?

Epistaxis Management

Immediate First-Line Treatment

For any patient with active epistaxis, apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without interruption, with the patient sitting upright and head tilted slightly forward. 1, 2, 3

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or stomach 2, 3
• Apply firm, continuous pressure to the soft lower third of the nose (the compressible cartilaginous portion, not the bony bridge) for at least 10-15 minutes without checking if bleeding has stopped during this time 1, 2, 3
• Instruct the patient to breathe through their mouth and spit out blood rather than swallowing it 2, 3
• Compression alone resolves the vast majority of anterior epistaxis cases 1, 2, 3

Common Pitfall to Avoid

• Insufficient compression time is the most common error—patients frequently check if bleeding has stopped before the full 10-15 minutes, which disrupts clot formation 2

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after 15 minutes of continuous compression, clear any clots from the nasal cavity first, then apply a topical vasoconstrictor such as oxymetazoline or phenylephrine. 2, 3, 4

• Spray 2 times in the bleeding nostril and continue compression for an additional 5 minutes 2
• This approach stops bleeding in 65-75% of epistaxis cases presenting to emergency departments 2, 4
• Vasoconstrictors may be associated with increased risk of cardiac or systemic complications in susceptible patients (elderly, cardiovascular disease) 3

Third-Line Treatment: Nasal Packing

For patients in whom bleeding persists despite compression and vasoconstrictors, or when bleeding precludes identification of a bleeding site, apply nasal packing. 1, 2

Packing Material Selection

• Use resorbable packing materials (such as Nasopore, Surgicel, Floseal, gelatin sponge, or fibrin glue) for patients on anticoagulants or antiplatelet medications 1, 2, 3, 4
• Resorbable packing reduces the likelihood of additional bleeding when removed and improves patient comfort 1
• Non-resorbable options include petroleum jelly gauze, BIPP gauze, PVA tampons (Merocel), or balloon devices (Rapid-Rhino) 4
• Newer hemostatic materials (thrombin matrix, gelatin sponge, fibrin glue) are more effective with fewer complications than traditional packing 4

Patient Education After Packing

• Educate the patient about the type of packing placed, timing and plan for removal (if not resorbable), post-procedure care, and warning signs requiring prompt reassessment 2

Fourth-Line Treatment: Cauterization

If an anterior bleeding site is clearly identified, electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs. 35.1%). 4

• Nasal endoscopy can localize the bleeding site in 87-93% of cases 3
• Chemical cauterization with silver nitrate is an alternative when electrocautery is unavailable 5
• Avoid bilateral simultaneous septal cautery due to risk of septal perforation 1

Alternative Pharmacologic Option: Tranexamic Acid

Topical tranexamic acid (TXA) promotes hemostasis in 78% of patients, superior to oxymetazoline (35%) and comparable to nasal packing (31%), with faster bleeding control and fewer rebleeds. 4, 6

• TXA stops bleeding within 10 minutes in 76% of patients compared to 34% with anterior nasal packing 6
• TXA is easily available, cheaper than gelfoam, and can be used as an elective method in emergency settings 6
• The role of TXA (topical or systemic) for acute treatment and prevention remains an area needing further research 1

Special Considerations for Anticoagulated Patients

In the absence of life-threatening bleeding, initiate first-line treatments (compression, vasoconstrictors, cautery, packing) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications. 2, 3

• Always use resorbable packing materials in this population 1, 2, 3

Indications for Escalation to Advanced Interventions

Escalate care when bleeding persists after 15 minutes of continuous pressure, duration exceeds 30 minutes over a 24-hour period, or patient shows signs of hemodynamic instability. 2, 3

Surgical and Interventional Options

• Endoscopic sphenopalatine artery (SPA) ligation is more effective than conventional nasal packing (97% vs. 62%) 4
• Endoscopic cauterization is more effective than ligation 4
• Endovascular embolization using gelatin sponge, foam, PVA, or coils has an 80% success rate with comparable efficacy and complications to surgical methods 4
• Recurrence rates: less than 10% for surgical artery ligation or embolization versus 50% for nasal packing alone 3

Prevention of Recurrent Epistaxis

Apply petroleum jelly or nasal emollients regularly to the nasal mucosa to prevent mucosal dryness and recurrence. 2, 3

• Use saline nasal sprays regularly to keep nasal mucosa moist 2, 3
• Recommend humidifiers, especially in dry environments 2
• Avoid picking or rubbing the nose to allow healing 3

Risk Factor Documentation

• Document factors increasing bleeding frequency or severity: personal/family history of bleeding disorders, anticoagulant/antiplatelet use, intranasal drug use, or intranasal tumors 1, 2, 3
• Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds (concern for hereditary hemorrhagic telangiectasia) 2

Follow-Up and Monitoring

Routine follow-up is recommended for patients who have undergone invasive treatments for epistaxis to assess for complications and recurrent bleeding within 30 days. 3

• Adequate follow-up allows assessment for underlying conditions (bleeding disorders, hematologic malignancies, intranasal tumors, vascular malformations) when treatments are ineffective or bleeding recurs 1, 3
• Educate patients and caregivers about home treatment techniques, preventive measures, and indications to seek additional medical care 2