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, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The management of a patient with resolved epistaxis at an urgent care should prioritize preventing recurrence and identifying any underlying causes.
- First, ensure the bleeding has completely stopped and assess vital signs to rule out significant blood loss.
- Recommend nasal saline sprays or gels (such as Ayr or Ocean spray) 2-3 times daily to keep the nasal mucosa moist, as dryness is a common cause of nosebleeds, as noted in the clinical practice guideline: nosebleed (epistaxis) executive summary 1.
- Advise the patient to avoid nose picking, forceful nose blowing, and strenuous activity for 24-48 hours.
- Suggest applying petroleum jelly to the anterior nasal septum with a cotton swab twice daily for 1-2 weeks.
- If the patient has had recurrent epistaxis, consider prescribing an antibiotic ointment like mupirocin (Bactroban) applied to the anterior nares twice daily for 5-7 days to prevent infection of any healing tissue.
- For patients on blood thinners, review their medication regimen but do not typically adjust doses for a single, resolved nosebleed, as suggested by the clinical practice guideline: nosebleed (epistaxis) 1.
- Instruct the patient to return if bleeding recurs and cannot be controlled with 15 minutes of direct pressure, if they experience frequent recurrences, or if they develop symptoms like persistent headache, visual changes, or significant blood in the throat, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. These management strategies address the common causes of epistaxis—mucosal dryness and trauma—while ensuring appropriate follow-up for potentially more serious conditions, and are in line with the guidelines provided by the American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) 1.
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.