How to manage epistaxis (nosebleed)?

How to Stop Epistaxis

Apply 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. 1

Immediate First-Line Management

Patient Positioning and Compression Technique

• Seat the patient upright with head tilted slightly forward to prevent blood from flowing into the airway or stomach 1
• Apply continuous pressure to the soft lower third of the nose (not the bony bridge) for a minimum of 10-15 minutes 2, 1
• The patient should breathe through their mouth and spit out blood rather than swallowing it 2, 1
• Do not release pressure early to check if bleeding has stopped—this is a common error that prevents adequate hemostasis 3
• Compression alone resolves the vast majority of anterior epistaxis cases 1

If Bleeding Continues After Initial Compression

• Clear the nasal cavity of clots by having the patient blow their nose once 4
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril 2, 1
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 4
• Vasoconstrictor application stops bleeding in 65-75% of emergency department cases 1, 5

Advanced Interventions When Compression Fails

Nasal Packing Indications

• Use nasal packing when bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors 2, 1
• Packing is also indicated for life-threatening bleeding or when a posterior bleeding source is suspected 1

Packing Material Selection

• For patients on anticoagulants or antiplatelet medications: Use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal 2, 1, 4
• For patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used 2
• Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) are more effective with fewer complications than traditional packing 5

Cauterization

• Perform anterior rhinoscopy to identify the bleeding site after clot removal 4
• Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 1, 5
• Nasal endoscopy localizes the bleeding site in 87-93% of cases 1, 3

Prevention of Recurrence

Immediate Post-Bleeding Care

• Apply petroleum jelly or lubricating agents to the nasal mucosa 2-3 times daily for at least one week 1, 4
• Use regular saline nasal sprays to keep nasal mucosa moist 1, 3
• Use a bedside humidifier, especially in dry environments 3, 4

Activity Restrictions

• Avoid nose blowing, strenuous activity, heavy lifting, or placing tissues/cotton in the nose for at least 7-10 days 4
• Avoid nasal manipulation and vigorous nose-blowing 1

Special Considerations for Anticoagulated Patients

Medication Management

• Continue anticoagulation in hemodynamically stable patients with controlled bleeding using local measures 1, 4
• Do not reverse anticoagulation unless bleeding is life-threatening—the thrombotic risk typically outweighs the bleeding risk from minor epistaxis 1, 4
• The decision to restart anticoagulation after major bleeding typically occurs within 24-48 hours after confirmation of hemostasis 1

Life-Threatening Bleeding Protocol

• Stop anticoagulation immediately only for major/life-threatening epistaxis 4
• Provide supportive care and volume resuscitation 4
• Consider reversal agents such as 4-factor prothrombin complex concentrate or andexanet alfa 4

When to Escalate Care

Indications for Emergency Department Evaluation

• Bleeding continues despite 15-30 minutes of proper compression 4
• Lightheadedness, weakness, or difficulty breathing due to blood in the airway 4
• Severe blood loss, hemodynamic instability, or hemoglobin drop ≥2 g/dL 4

Indications for ENT Referral or Advanced Intervention

• If nasal packing fails or there is recurrent bleeding, evaluate for surgical ligation or endovascular embolization 1, 3
• Endoscopic cauterization is more effective than arterial ligation 5
• Embolization using gelatin sponge, foam, PVA, or coils has an 80% success rate with comparable efficacy to surgical methods 5
• Recurrence rates: less than 10% for surgical artery ligation or embolization versus 50% for nasal packing alone 1

Follow-Up Requirements

• Document outcome within 30 days of any invasive intervention to assess for complications and recurrent bleeding 1, 3, 4
• Reassess if bleeding recurs despite preventive measures 3