From the Guidelines
For a patient with resolved epistaxis at an urgent care, the management should focus on preventing recurrence and identifying any underlying causes, with the most recent guidelines from 2024 suggesting a conservative approach with nasal saline sprays, humidification, and avoidance of strenuous activities 1. The patient should be assessed for hemodynamic stability and any signs of ongoing bleeding.
- Recommend nasal saline sprays or gels (such as Ocean spray) 2-3 times daily to keep the nasal mucosa moist, and petroleum jelly applied to the anterior septum twice daily using a cotton swab.
- Advise the patient to avoid nose picking, forceful nose blowing, and strenuous activity for 24-48 hours.
- Recommend humidification of the home environment, especially in dry climates. If the patient is on anticoagulants or antiplatelet medications, these should generally be continued unless bleeding was severe or recurrent, in which case consultation with the prescribing physician is warranted 1. For patients with hypertension, ensure adequate blood pressure control. If the epistaxis was significant or recurrent, consider prescribing tranexamic acid 500 mg orally three times daily for 5-7 days to stabilize clots, although the most recent guidelines do not specifically address this point, previous guidelines suggest its use in certain cases 1. Follow-up should be recommended if bleeding recurs, is severe, or if there are concerns about an underlying condition such as coagulopathy or nasal masses. These measures help prevent recurrence by maintaining mucosal integrity and optimizing the coagulation process while addressing common contributing factors.
From the Research
Management of Epistaxis
- The management of a patient with epistaxis that has already resolved involves assessing the patient's vital signs, mental status, and airway patency 2.
- A thorough examination of the nose using a nasal speculum and a good light source can help identify the source of bleeding 2.
- Compressive therapy is the first step in controlling anterior epistaxis, and oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 may be useful adjuncts 2.
Considerations for Patients on Anticoagulant or Antiplatelet Medication
- Patients taking anticoagulant or antiplatelet medication may require special consideration, as these medications can increase the risk of bleeding and worsen outcomes 3, 4.
- A treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients can help standardize management and reduce morbidity associated with unnecessary discontinuation of medication 3.
- The decision to withhold anticoagulant or antiplatelet medication should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history 3, 4.
Initial Assessment and Treatment
- The initial assessment of epistaxis patients should include first aid measures, observations, focused history taking, and clinical examinations and investigations 5.
- Coagulation screening is useful in patients on anticoagulant medication, and oral ice pack use may decrease severity and can be considered as first aid 5.
- The treatment of epistaxis in patients taking factor Xa inhibitors, warfarin, or antiplatelet agents may involve different approaches, and the choice of treatment should be tailored to the individual patient's needs 6.