What is the appropriate management for a patient presenting with epistaxis, considering potential underlying conditions such as bleeding disorders or anticoagulant use?

Management of Epistaxis

Immediate Assessment and First-Line Treatment

For any patient presenting with epistaxis, begin with firm sustained compression to the lower third of the nose for 5-15 minutes with the patient seated and head tilted slightly forward, breathing through the mouth—this is the single most important initial intervention regardless of underlying conditions. 1

Initial Triage

Distinguish immediately whether the patient requires emergent management by assessing for: 1

• Airway compromise from bleeding into the oropharynx
• Hemodynamic instability (tachycardia, hypotension, altered mental status)
• Posterior epistaxis (bleeding from sites not visible on anterior rhinoscopy)
• Hemoglobin drop ≥2 g/dL

Patients with any of these features require emergency department evaluation. 1

First-Line Local Control Measures

After or during initial compression: 1

1. Remove blood clots by suction or gentle nose blowing to identify the bleeding site 2

2. Apply topical vasoconstrictors: Oxymetazoline or phenylephrine spray (2-3 sprays per nostril), which stops bleeding in 65-75% of cases 1, 3

   • Apply to cotton pledget if spray ineffective
   • Continue compression for 5 additional minutes after application 4

3. Identify and cauterize the bleeding site if visible after clot removal:

   • Anesthetize the area first 1
   • Use silver nitrate or electrocautery restricted only to the active bleeding site 1
   • Electrocautery has fewer recurrences than chemical cautery (14.5% vs 35.1%) 5

4. Apply nasal packing only if bleeding persists despite above measures 1

Special Considerations for Anticoagulation/Antiplatelet Therapy

In patients on anticoagulants or antiplatelets, prioritize aggressive local control measures first—do NOT reverse anticoagulation or withhold medications unless there is life-threatening bleeding. 1, 6, 2

Critical Management Principle

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends initiating first-line treatments (compression, vasoconstrictors, cautery) prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications in the absence of life-threatening bleeding. 1, 6 Withholding anticoagulation increases thrombotic risk, which carries higher morbidity and mortality than epistaxis itself. 2

Packing Material Selection

Use resorbable packing materials (such as Nasopore) for patients on anticoagulants or with suspected bleeding disorders. 1, 4, 6 This avoids the trauma of pack removal in patients with impaired hemostasis.

Reversal Strategies (Only for Severe/Life-Threatening Bleeding)

If local control fails and bleeding is severe with hemodynamic compromise: 1

• Warfarin: 4-factor prothrombin complex concentrate (PCC) or fresh frozen plasma + vitamin K
• Heparin/LMWH: Protamine sulfate
• DOACs (dabigatran, apixaban, rivaroxaban): 4-factor PCC; idarucizumab for dabigatran specifically
• Antiplatelet agents (aspirin, clopidogrel): Platelet transfusion (may be ineffective if active drug present)

Important caveat: Discuss with the primary service managing anticoagulation before fully reversing, as reversal agents carry significant risks including thrombotic complications. 1

Prevention and Long-Term Management

After bleeding control is achieved: 1, 6

• Apply petroleum jelly or other emollients to the nasal mucosa to prevent recurrence
• Prescribe saline nasal sprays for regular use to maintain mucosal moisture
• Recommend humidifier use, especially in dry environments 4
• Document factors that increase bleeding frequency or severity (medications, environmental factors, nasal trauma) 1, 2

When to Perform Nasal Endoscopy

Perform or refer for nasal endoscopy in: 1, 2

• Recurrent epistaxis despite prior treatment
• Difficulty controlling bleeding with initial measures
• Concern for unrecognized pathology (tumor, foreign body)
• Recurrent bilateral nosebleeds (to assess for hereditary hemorrhagic telangiectasia) 2

Escalation to Advanced Interventions

If bleeding persists despite packing or recurs after pack removal, evaluate candidacy for: 1, 2

• Surgical arterial ligation (endoscopic sphenopalatine artery ligation has highest success rates—97% vs 62% for packing alone) 2, 5
• Endovascular embolization (80% success rate, comparable efficacy to surgical methods) 5

Common Pitfalls to Avoid

• Insufficient compression time: Must maintain pressure for full 10-15 minutes without checking if bleeding stopped 4, 6
• Premature anticoagulation reversal: Increases thrombotic risk unnecessarily when local measures would suffice 1, 2
• Excessive or bilateral cautery: Can damage nasal septum and mucosa 1
• Neglecting prevention: Failing to address nasal dryness leads to recurrent episodes 4, 2
• Discontinuing intranasal corticosteroids: If patient uses these, they should be stopped as they increase epistaxis risk (RR 2.74) 2

Patient Education

Educate all patients about: 1, 6

• Home treatment: Proper compression technique, when to use over-the-counter vasoconstrictors
• Prevention: Nasal moisturization, humidification, avoiding nose picking
• Red flags: Seek immediate care if bleeding lasts >15 minutes despite compression, dizziness occurs, or signs of hemodynamic instability develop 4
• Follow-up: Document outcome within 30 days 1