How do you treat epistaxis?

Epistaxis Management

For active epistaxis, immediately apply firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped—this single intervention resolves the vast majority of cases. 1, 2

Immediate First-Line Management

Patient Positioning and Compression

• Position the patient sitting upright with head tilted slightly forward (not backward) to prevent blood from flowing into the airway or stomach 3, 2, 4
• Apply firm, continuous pressure to the soft lower third of the nose (not the nasal bridge) for a minimum of 10-15 minutes without interruption 1, 3, 2
• The patient should breathe through their mouth and spit out blood rather than swallowing it 3, 2
• Compression alone resolves the vast majority of anterior epistaxis cases 1, 2

Common Pitfall: Most treatment failures occur because compression time is insufficient or the wrong location is compressed—only 30% of healthcare providers correctly identify the proper compression site 5

Topical Vasoconstrictors (If Compression Fails)

• After 10-15 minutes of compression, if bleeding persists, clear clots from the nose and apply topical vasoconstrictor spray (oxymetazoline or phenylephrine)—2 sprays into the bleeding nostril 1, 3, 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 3, 2
• Vasoconstrictors resolve 65-75% of epistaxis cases in emergency departments 2, 6
• Caution: Vasoconstrictors may cause cardiac or systemic complications in susceptible patients 2

Advanced Interventions When Basic Measures Fail

Nasal Cauterization

• If an anterior bleeding site is identified, electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 2, 6
• Silver nitrate cautery can be applied to localized bleeding sites or prominent vessels 7
• Nasal endoscopy localizes the bleeding site in 87-93% of cases 2

Nasal Packing

• Indicated when bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors, for life-threatening bleeding, or when a posterior bleeding source is suspected 1, 2
• For patients on anticoagulants or antiplatelet medications: Use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal 1, 2, 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 6

Critical Medication Management

Anticoagulant/Antiplatelet Considerations

• Do not withhold, reverse anticoagulation, or administer blood products for non-life-threatening epistaxis 1, 4
• First-line local control measures should always be attempted before considering any anticoagulation reversal 4
• For aspirin in high-risk cardiovascular patients (recent MI or stents), continue aspirin despite epistaxis—survival benefits outweigh bleeding risks 2
• Reversal agents (4-factor prothrombin complex concentrate) should only be used for life-threatening bleeding due to significant thrombotic risk 4

NSAID-Related Epistaxis

• Manage with standard epistaxis protocol without discontinuing NSAIDs unless bleeding cannot be controlled with local measures 2
• NSAIDs cause significant platelet dysfunction but standard epistaxis alone is not an indication to stop 2

Prevention of Recurrence

• Apply petroleum jelly or other lubricating agents to the nasal mucosa once bleeding stops 1, 3, 2, 4
• Use saline nasal sprays regularly to keep nasal passages moist 3, 2, 4
• Consider using a humidifier, especially in dry environments 3, 4
• Avoid nose picking, vigorous nose blowing, and nasal decongestants for at least 7-10 days 2

When to Escalate Care

Indications for Prompt Management

• Distinguish patients requiring prompt management based on bleeding duration, hemodynamic instability (tachycardia, hypotension), or history of hospitalization for epistaxis 1, 2
• Seek immediate medical attention if bleeding does not stop after 15 minutes of continuous pressure 3, 4
• Signs requiring urgent evaluation: dizziness from blood loss, severe bleeding (>30 minutes duration over 24 hours), hemodynamic instability 3

Surgical Options for Refractory Cases

• Endoscopic sphenopalatine artery ligation has 97% success rate versus 62% for conventional packing 2, 6
• Endovascular embolization has 80% success rate with comparable efficacy to surgical methods 2, 6
• Both surgical ligation and embolization have lower recurrence rates (<10%) compared to nasal packing (50%) 2, 6

Documentation Requirements

• Document factors increasing bleeding frequency or severity: personal or family history of bleeding disorders, anticoagulant or antiplatelet use, intranasal drug use 1, 2
• Follow-up within 30 days for patients who underwent invasive treatments to assess complications and recurrent bleeding 2

Note on Ice Packs: Current evidence does not support ice packs as a first aid intervention for acute epistaxis—it does not significantly change nasal blood flow or volume 2