What is the initial management of epistaxis (nosebleed)?

Initial Management of Epistaxis

The first-line treatment for epistaxis is firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without releasing pressure to check if bleeding has stopped, with the patient sitting upright and head tilted slightly forward. 1, 2

Immediate First Steps

Patient Positioning and Compression

• Seat the patient upright with head tilted slightly forward to prevent blood from flowing into the airway or stomach 2
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 1, 2
• Apply firm, continuous pressure by pinching the soft lower third of the nose for at least 10-15 minutes without interruption 1, 2
• Compression alone resolves the vast majority of anterior epistaxis cases 2

Critical pitfall: Do not release pressure early to check if bleeding has stopped—this disrupts clot formation and prolongs bleeding 2

Second-Line: Topical Vasoconstrictors (If Compression Fails)

• After 15 minutes of compression, if bleeding persists, have the patient blow their nose once to clear clots 1, 2
• Apply oxymetazoline or phenylephrine nasal spray (2 sprays in the bleeding nostril) 1, 3
• Continue holding pressure for another 5-10 minutes after vasoconstrictor application 2, 4
• Vasoconstrictors stop bleeding in 65-75% of cases that don't respond to compression alone 2, 5, 6

Alternative: Cotton pledgets soaked in oxymetazoline or epinephrine 1:1,000 can be inserted into the nose with continued compression 1, 6

Third-Line: Identify Bleeding Site

Anterior Rhinoscopy

• Once bleeding slows or stops, perform anterior rhinoscopy to identify the bleeding source after removing any blood clots 1
• Use a nasal speculum and good light source (headlamp preferred) for visualization 6
• More than 90% of epistaxis cases arise from the anterior nasal circulation 6

Nasal Cautery (If Bleeding Site Identified)

• When a bleeding site is clearly visible, anesthetize the area and apply cautery restricted only to the active or suspected bleeding site 1
• Bipolar electrocautery is more effective than chemical cautery (silver nitrate), with fewer recurrences (14.5% vs 35.1%) 2, 5
• Chemical cautery with silver nitrate is acceptable but less effective 5, 6

Important caveat: Excessive cautery can damage nasal mucosa and increase risk of septal perforation 2

Fourth-Line: Nasal Packing (If Above Measures Fail)

When to Pack

• Use nasal packing when bleeding precludes identification of a bleeding site despite compression, or when bleeding is life-threatening 1
• Packing is indicated for failure of compression, vasoconstrictors, and cautery 2

Type of Packing Material

• Use resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal, gelatin sponge) for patients with suspected bleeding disorders or those taking anticoagulants/antiplatelet medications 1, 4
• Resorbable packing reduces the risk of rebleeding when removed and improves patient comfort 1
• Non-resorbable packing (petroleum jelly gauze, BIPP, Merocel, Foley catheter) can be used in patients without bleeding risk factors 5

Critical consideration: Patients with hereditary hemorrhagic telangiectasia (HHT) should always receive resorbable packing, as removal of non-resorbable materials can trigger severe rebleeding 1

Prevention of Recurrence

• Apply petroleum jelly or nasal saline gel to the anterior nasal septum 2-3 times daily for at least one week after bleeding stops 2, 7, 4
• Use regular saline nasal sprays to keep nasal mucosa moist 1, 2, 7
• Recommend bedside humidifier use, especially in dry climates 1, 2, 4
• Advise patients to avoid nose picking, vigorous nose blowing, and nasal manipulation for 7-10 days 4

When to Escalate Care

Indications for Emergency Department or ENT Referral

• Bleeding continues despite 15-30 minutes of proper compression and vasoconstrictor application 2, 7, 4
• Signs of hemodynamic instability, significant blood loss, or hemoglobin drop ≥2 g/dL 4
• Patient experiences dizziness, weakness, lightheadedness, or difficulty breathing 7, 4
• Suspected posterior epistaxis (bleeding continues despite anterior measures or blood flows into posterior pharynx during compression) 1, 6

Advanced Interventions (Specialist-Level)

• Nasal endoscopy to examine the nasal cavity and nasopharynx when bleeding is difficult to control or there is concern for unrecognized pathology 1, 2
• Endoscopy localizes the bleeding site in 87-93% of cases 2
• For refractory cases: endoscopic arterial ligation (particularly sphenopalatine artery) or endovascular embolization 2, 5
• Surgical ligation and embolization have recurrence rates less than 10%, compared to 50% for nasal packing alone 2

Special Populations

Patients on Anticoagulants/Antiplatelets

• Continue anticoagulation and use first-line local treatments before considering medication withdrawal, except in life-threatening bleeding 2, 4
• The thrombotic risk from stopping anticoagulation typically outweighs the bleeding risk from minor epistaxis 4
• Mandatory use of resorbable packing if packing becomes necessary 1, 4
• Coordinate with the prescribing physician before any medication changes 4

Pediatric Patients

• Same compression technique applies: 10-15 minutes of firm pressure to lower third of nose 7
• Mean age of presentation is 7.5 years; epistaxis typically originates from anterior septum (Kiesselbach's plexus) 7
• Only 6.9% of pediatric cases require procedures beyond compression and topical agents 7

Documentation and Follow-Up

• Document the outcome of intervention within 30 days for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 1
• Patients requiring any invasive intervention should have documented follow-up to assess for complications and recurrent bleeding 2, 4
• Educate patients about warning signs requiring immediate medical attention: fever >101°F, vision changes, shortness of breath, facial swelling, or increasing pain 4