Epistaxis: Causes and Treatment
Causes of Epistaxis
The most common causes of epistaxis include local trauma (nose picking, nasal manipulation), environmental factors (dry air, low humidity), anticoagulant or antiplatelet medications, hypertension, intranasal drug use, and underlying bleeding disorders. 1, 2
Key Etiologic Factors to Document:
- Personal or family history of bleeding disorders (consider hereditary hemorrhagic telangiectasia if recurrent bilateral epistaxis with nasal/oral telangiectasias) 1, 2
- Anticoagulant or antiplatelet medication use 1, 2
- Recent nasal trauma or septal fracture 2
- Intranasal drug use 1, 2
- Environmental dryness (low humidity environments) 1, 2
Immediate Treatment Algorithm
Step 1: Initial Compression (First-Line Treatment)
Apply firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped during this time. 1, 2
- Position patient sitting upright with head tilted slightly forward to prevent blood from flowing into airway or stomach 1, 2
- Patient should breathe through mouth and spit out blood rather than swallowing it 1, 2
- Compression alone resolves the vast majority of anterior epistaxis cases 1, 2
Step 2: Topical Vasoconstrictors (If Bleeding Persists After 10-15 Minutes)
Clear any clots from the nasal cavity first, then apply oxymetazoline or phenylephrine spray 2 times in the bleeding nostril and continue compression for an additional 5-10 minutes. 1, 2
- This approach resolves 65-75% of epistaxis cases presenting to emergency departments 1, 2, 3
- Note: Vasoconstrictors may carry increased risk of cardiac or systemic complications in susceptible patients 2
Step 3: Advanced Interventions (If Above Measures Fail After 15-30 Minutes)
Topical Tranexamic Acid (Emerging Evidence)
Topical application of injectable tranexamic acid (500 mg in 5 mL) is probably more effective than traditional nasal packing, stopping bleeding within 10 minutes in 70-78% of patients compared to 30-35% with other agents. 3, 4, 5, 6
- Tranexamic acid reduces re-bleeding risk from 67% to 47% within 10 days (moderate-quality evidence) 4
- Application is simple: apply topically to bleeding site after clearing clots 5, 6
- Rebleeding rates are lower (4.7%) compared to nasal packing (11%) 6
Nasal Packing (Traditional Approach)
Use nasal packing when bleeding continues despite proper compression with vasoconstrictors, for life-threatening bleeding, or when posterior bleeding source is suspected. 2
- For patients on anticoagulants or antiplatelet medications, use only resorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal 1, 2
- For patients without bleeding risk factors, either resorbable or non-resorbable materials may be used 2
- Educate patient about packing type, removal timing (if not resorbable), and warning signs requiring reassessment 1
Cauterization
Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) when an anterior bleeding site is identified. 2, 3
Special Considerations for Anticoagulated Patients
Initiate first-line treatments (compression, vasoconstrictors, cautery, packing) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications. 1, 2
- Do not reverse anticoagulation in hemodynamically stable patients with controlled bleeding using local measures 2
- Decision to restart anticoagulation should balance thrombosis and bleeding risk, typically within 24-48 hours after hemostasis confirmation 2
When to Escalate Care
Seek immediate medical attention if:
- Bleeding persists after 15 minutes of continuous proper compression 1, 2
- Bleeding duration exceeds 30 minutes over a 24-hour period 1
- Patient shows signs of hemodynamic instability (tachycardia, hypotension) or dizziness from blood loss 1, 2
- Persistent or recurrent bleeding not controlled by packing or cauterization 1
Advanced Surgical Options (For Refractory Cases)
- Endoscopic sphenopalatine artery ligation (97% success rate vs 62% for conventional packing) 3
- Endovascular embolization (80% success rate, comparable efficacy to surgical methods) 3
- Recurrence rates: <10% for surgical ligation or embolization vs 50% for nasal packing 2
Prevention of Recurrence
Apply petroleum jelly or nasal emollients regularly to prevent mucosal dryness once bleeding has stopped. 1, 2
- Use saline nasal sprays to keep nasal mucosa moist 1, 2
- Recommend humidifiers, especially in dry environments 1, 2
- Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after treatment 2
Common Pitfalls to Avoid
- Insufficient compression time: Must maintain pressure for full 10-15 minutes without checking 7, 2
- Checking too early: Interrupting compression before 10 minutes prevents clot formation 1, 2
- Neglecting prevention: Not treating underlying nasal mucosa dryness leads to recurrent episodes 7
- Inappropriate packing material: Using non-resorbable packing in anticoagulated patients increases trauma risk 1, 2
Note on Cryotherapy
Current evidence does not support the use of ice packs (to neck, forehead, or intraorally) as a first aid intervention for acute epistaxis. 8
- Gray literature recommendations are based on theory of vasoconstriction, but studies show no significant change in nasal blood flow or volume with cryotherapy application 8