What is the approach to managing epistaxis?

Approach to Epistaxis Management

Immediate First-Line Treatment

Position the patient sitting upright with head tilted slightly forward (not backward) and apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped during this time. 1, 2, 3

• The patient should breathe through their mouth and spit out blood rather than swallowing it to prevent nausea and allow assessment of ongoing bleeding 2, 3
• Compression alone resolves the vast majority of anterior epistaxis cases (>90% of all epistaxis) 2, 3, 4
• Common pitfall: Patients frequently check if bleeding has stopped before 10-15 minutes, which disrupts clot formation and prolongs bleeding 2, 3
• Common pitfall: Tilting the head backward is incorrect—this causes blood to flow into the airway or stomach rather than stopping the bleed 2, 3

Second-Line Treatment (If Bleeding Persists After Compression)

If bleeding continues after 10-15 minutes of proper compression, clear any clots from the nasal cavity, then apply a topical vasoconstrictor (oxymetazoline or phenylephrine) and resume compression for an additional 5 minutes. 1, 2, 3

• Spray the vasoconstrictor 2 times into the bleeding nostril 2
• This approach stops bleeding in 65-75% of epistaxis cases presenting to emergency departments 2, 3, 5
• Vasoconstrictors can also be applied using cotton pledgets soaked in oxymetazoline or epinephrine 1:1,000 1, 4
• Caution: Vasoconstrictors may cause cardiac or systemic complications in susceptible patients (those with cardiovascular disease, hypertension) 3

Third-Line Treatment: Nasal Packing

Use nasal packing only when compression and vasoconstrictors fail, when bleeding is life-threatening, or when a posterior bleeding source is suspected (blood flowing into posterior pharynx during compression). 1, 2, 3

Packing Material Selection:

• For patients on anticoagulants or antiplatelet medications: Use resorbable packing materials (such as Nasopore, Surgicel, Floseal, or gelatin sponge) to reduce bleeding risk when packing is removed 1, 2, 3, 6, 5
• For patients not on anticoagulants: Either resorbable or non-resorbable materials (Merocel, petroleum jelly gauze, Rapid-Rhino balloon) can be used 1, 5
• Newer hemostatic materials (thrombin matrix, fibrin glue, hemostatic gauzes) are more effective with fewer complications than traditional packing 5

Special Considerations for Anticoagulated Patients

Initiate first-line treatments (compression, vasoconstrictors, cautery, packing) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications, unless bleeding is life-threatening. 2, 6

• This approach prioritizes maintaining therapeutic anticoagulation for the underlying indication (stroke prevention, thrombosis prevention) while still controlling epistaxis 2, 6

When to Escalate Care

Refer to otolaryngology or emergency department if: 2, 3

• Bleeding persists after 15 minutes of continuous proper compression 2, 3
• Total bleeding duration exceeds 30 minutes over a 24-hour period 2, 6
• Signs of hemodynamic instability (tachycardia, hypotension, dizziness from blood loss) 2, 6
• Persistent or recurrent bleeding despite packing 2
• Suspected posterior epistaxis (more common in elderly, associated with hypertension and atherosclerosis) 7, 4

Advanced Interventions (Specialist-Level)

For refractory cases requiring specialist management: 3, 5

• Cauterization: Electrocautery is more effective than chemical cauterization (14.5% vs 35.1% recurrence rates) when an anterior bleeding site is identified 3, 5
• Endoscopic arterial ligation: More effective than conventional packing (97% vs 62% success rate), particularly sphenopalatine artery ligation 5
• Endovascular embolization: 80% success rate for intractable cases, comparable efficacy to surgical methods 5

Prevention of Recurrence

Once bleeding stops, apply petroleum jelly or nasal emollients to the nasal mucosa regularly to prevent recurrence. 2, 3

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

Important Historical Factors to Document

Obtain history regarding: 1, 3

• Personal or family history of bleeding disorders 1, 3
• Current use of anticoagulants or antiplatelet medications 1, 3
• Intranasal drug use 3
• For recurrent bilateral epistaxis: Assess for nasal and oral mucosal telangiectasias (concern for hereditary hemorrhagic telangiectasia) 2

Patient Education

Educate patients and caregivers about: 2

• Proper home compression technique (10-15 minutes, head forward, no peeking) 2
• Preventive measures (nasal moisturization, humidification) 2
• Warning signs requiring immediate medical attention (persistent bleeding >15 minutes, dizziness, hemodynamic instability) 2
• Type of packing placed (if applicable), timing for removal, and post-procedure care 2