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

Treatment for Nosebleed (Epistaxis)

For active nosebleeds, apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped, with the patient sitting upright and head tilted slightly forward. 1

Immediate First-Line Management

Patient Positioning and Compression Technique

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 2, 3
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 2, 3
• Apply continuous firm pressure by pinching the soft lower third of the nose for a minimum of 10-15 minutes without interruption to check if bleeding has stopped 1, 3
• This compression technique alone stops bleeding in the vast majority of anterior epistaxis cases 1, 3

Common pitfall: Patients frequently check if bleeding has stopped before 10-15 minutes, which disrupts clot formation and prolongs bleeding. 3

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after adequate compression:

• Clear any blood clots from the nasal cavity first 1, 3
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) - 2 sprays into the bleeding nostril 2, 3, 4
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 3
• This approach resolves 65-75% of nosebleeds that don't stop with compression alone 2, 5, 6

Note: Vasoconstrictors may be associated with increased risk of cardiac or systemic complications in susceptible patients. 3

Third-Line Treatment: Cauterization

If a bleeding site is clearly visible on anterior rhinoscopy after failed compression and vasoconstrictors:

• Anesthetize the bleeding site before cauterization 1
• Restrict cautery application only to the active or suspected site(s) of bleeding 1
• Electrocautery (bipolar) is preferable to chemical cautery (silver nitrate) as it is more effective with fewer recurrences (14.5% vs 35.1%) 2, 5
• Avoid vigorous cauterization as it can damage the nasal lining 3

Fourth-Line Treatment: Nasal Packing

Nasal packing is indicated when: 1, 3

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors
• Life-threatening bleeding is present
• A posterior bleeding source is suspected

Packing Material Selection

• For patients on anticoagulants or antiplatelet medications: use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) 1, 3
• For patients without bleeding risk factors: either resorbable or non-resorbable materials may be used 3
• Resorbable materials reduce trauma during removal 3

Patient Education for Nasal Packing

Educate patients who undergo nasal packing about: 1

• Type of packing placed
• Timing and plan for removal (if not resorbable)
• Post-procedure care
• Signs or symptoms warranting prompt reassessment

Prevention of Recurrence

Once bleeding has stopped: 1, 2

• Apply petroleum jelly (Vaseline) or other moisturizing/lubricating agents to the anterior nasal septum
• Use saline nasal sprays regularly to keep nasal mucosa moist
• Consider using a humidifier, especially in dry environments
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days 3

Special Considerations for Anticoagulated Patients

In the absence of life-threatening bleeding, initiate first-line treatments (compression, vasoconstrictors, cautery) prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications. 1, 7

• Do not reverse anticoagulation in hemodynamically stable patients with controlled bleeding using local measures 3
• If anticoagulation restart is needed, this typically occurs within 24-48 hours after confirmation of hemostasis 3

Advanced Interventions for Refractory Cases

If bleeding persists despite packing or recurs: 1

• Perform nasal endoscopy to identify the bleeding site (successful in 87-93% of cases) 3, 5
• Evaluate candidacy for surgical arterial ligation (particularly sphenopalatine artery) - 97% success rate 3, 5
• Consider endovascular embolization - 80% success rate 3, 5
• Both surgical and embolization approaches have recurrence rates less than 10%, compared to 50% for nasal packing alone 3, 5

When to Seek Emergency Medical Attention

Direct patients to emergency department if: 2, 3

• Bleeding does not stop after 15 minutes of continuous proper compression
• Patient experiences dizziness, weakness, or lightheadedness suggesting significant blood loss
• Bleeding duration exceeds 30 minutes over a 24-hour period
• Signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension) are present

Documentation and Follow-Up

• Document factors that increase bleeding frequency or severity: personal or family history of bleeding disorders, anticoagulant or antiplatelet use, intranasal drug use 1, 3
• Document outcome of intervention within 30 days or document transition of care 1
• Assess for nasal telangiectasias and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds 1

Note: The American Heart Association states that current evidence does not support the use of ice packs as a first aid intervention for acute epistaxis, as it does not significantly change nasal blood flow or volume. 3