What is the treatment for a nose bleed (epistaxis)?

Treatment of Epistaxis (Nosebleed)

For an active nosebleed, have the patient sit upright with head tilted slightly forward and apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without interruption—this alone resolves the vast majority of cases. 1, 2

Immediate First-Line Management

Patient Positioning and Direct Pressure

• Position the patient sitting upright with head tilted forward (not backward) to prevent blood from flowing into the airway or being swallowed 2, 3
• Apply firm, sustained compression to the soft lower third of the nose (not the nasal bridge) for at least 10-15 minutes continuously without checking if bleeding has stopped 1, 2
• The patient should breathe through their mouth and spit out blood rather than swallowing it 1, 2
• Compression alone stops bleeding in 90-95% of anterior epistaxis cases 4

Common Pitfall: Most healthcare providers incorrectly identify where to apply pressure—only 30% know the correct compression site 4. The key is pinching the soft cartilaginous part, not the bony bridge.

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after 15 minutes of adequate compression:

• Clear the nasal cavity of clots by having the patient blow their nose 1
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine—both available over-the-counter) with 2 sprays into the bleeding nostril 1
• Continue holding pressure for another 5 minutes 1
• This approach stops bleeding in 65-75% of emergency department cases 1, 2, 5

Caution: Vasoconstrictors may increase risk of cardiac or systemic complications in patients with hypertension, cardiovascular disease, or glaucoma 1, 2. Repeated use can cause rhinitis medicamentosa and loss of efficacy 1.

Third-Line Treatment: Cautery

When an anterior bleeding site is identified and accessible:

• Chemical cautery (silver nitrate) or electrocautery can be performed, typically with local anesthesia 1
• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 2, 5
• Avoid bilateral cautery on the septum to minimize risk of septal perforation 1
• Nasal endoscopy can localize the bleeding site in 87-93% of cases 2

Fourth-Line Treatment: Nasal Packing

Indications for nasal packing include 2, 3:

• Failure of compression, vasoconstrictors, and cautery
• Life-threatening bleeding
• Posterior bleeding source
• Bleeding that precludes identification of the source

Packing Material Selection

• For patients on anticoagulants or antiplatelet medications: Use resorbable/absorbable packing materials (e.g., Nasopore, gelatin sponge, hemostatic gauze) 1, 2, 3
• For other patients: Non-resorbable materials (petroleum jelly gauze, BIPP gauze, PVA tampons like Merocel, or balloon devices like Rapid-Rhino) may be used 3, 5
• Newer hemostatic materials (Surgicel, Floseal, Spongostan, fibrin glue) are more effective with fewer complications 5

Critical Point: Resorbable packing avoids trauma during removal, which can trigger rebleeding—this is especially important for anticoagulated patients 1, 3.

Prevention of Recurrence

Once bleeding stops:

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 1-3 times daily 1, 2
• Use saline nasal spray regularly to keep mucosa moist 1, 2
• Consider bedside humidifier, especially in dry environments 1
• Avoid nose picking, vigorous nose blowing, strenuous activity, and heavy lifting for at least 7-10 days 1, 2

When to Escalate Care

Seek immediate medical attention or call 911 if 1:

• Bleeding does not stop after 15 minutes of continuous pressure
• Bleeding is severe or persistent (>30 minutes over 24 hours)
• Patient feels weak, lightheaded, or shows signs of hemodynamic instability

Advanced Interventions

For refractory or recurrent epistaxis:

• Endoscopic arterial ligation (primarily sphenopalatine artery) is more effective than conventional packing (97% vs 62%) 5
• Endoscopic cauterization is more effective than ligation 5
• Arterial embolization using gelatin sponge, foam, PVA, or coils has 80% success rate for intractable cases 5
• Recurrence rates: <10% for surgical ligation/embolization versus 50% for nasal packing alone 2

Special Considerations for Anticoagulated Patients

• Do not routinely reverse anticoagulation for epistaxis in hemodynamically stable patients with controlled bleeding using local measures 2
• Only consider reversal for life-threatening hemorrhage 2
• Consult the prescribing clinician before holding anticoagulation, as these medications treat serious underlying conditions 1
• Anticoagulation typically restarts within 24-48 hours after confirmed hemostasis 2

Follow-Up and Documentation

• Document outcome within 30 days for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 1, 3
• Educate patients about warning signs requiring reassessment and preventive measures 1, 2, 3
• Post-cautery restrictions: avoid nose blowing, strenuous activity, heavy lifting, or inserting anything into the nose for at least one week 1