What is the recommended treatment for an adult patient with no significant medical history presenting with epistaxis (nosebleed)?

Recommended Treatment for Epistaxis

For an adult with epistaxis and no significant medical history, begin with firm continuous compression of the soft lower third of the nose for a full 10-15 minutes without interruption, with the patient seated and head tilted slightly forward—this alone resolves the vast majority of anterior epistaxis cases. 1

Immediate First-Line Management

Patient Positioning and Compression

• Seat the patient upright with head tilted slightly forward to prevent blood from flowing into the airway or stomach 1
• Apply firm, sustained pressure to the soft lower third of the nose (not the nasal bridge) for a minimum of 10-15 minutes continuously 1, 2
• Critical pitfall: Do not check if bleeding has stopped during the compression period, as premature release restarts bleeding 1
• Instruct the patient to breathe through their mouth and spit out blood rather than swallowing it 1, 2

Vasoconstrictor Application (If Compression Alone Fails)

• After initial compression, clean the nasal cavity of blood clots by suction or gentle nose blowing 3
• Apply topical vasoconstrictor spray: oxymetazoline or phenylephrine 2 sprays into the bleeding nostril 1
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 1
• Efficacy: Vasoconstrictor application stops bleeding in 65-75% of emergency department cases 1, 4
• Caution: May be associated with increased risk of cardiac or systemic complications in susceptible patients 1

Visualization and Localization

Anterior Rhinoscopy

• Perform anterior rhinoscopy to identify the bleeding source after clot removal 3, 2
• Most nosebleeds originate from the anterior septum (Kiesselbach's plexus/Little's area) 2
• Critical pitfall: Skipping clot removal before visualization prevents accurate identification of the bleeding source 2

Nasal Endoscopy (When Indicated)

• Perform or refer for nasal endoscopy if: 3, 2
  • Recurrent bleeding despite prior treatment with packing or cautery
  • Recurrent unilateral nasal bleeding (concern for tumor or vascular malformation)
  • Bleeding is difficult to control
  • Anterior rhinoscopy fails to identify the source
• Nasal endoscopy localizes the bleeding site in 87-93% of cases 1

Definitive Treatment Options

Chemical or Electrocautery (If Bleeding Site Identified)

• Apply directed cautery to the identified bleeding site, most commonly using silver nitrate 5
• Electrocautery is superior: 14.5% recurrence rate versus 35.1% for chemical cauterization 1, 4
• Critical warning: Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 3, 6

Nasal Packing (If Other Methods Fail)

• Indications for nasal packing: 1

  • Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors
  • Life-threatening bleeding
  • Posterior bleeding source suspected

• Material selection based on anticoagulation status: 1, 2

  • Patients on anticoagulants/antiplatelet medications: Use ONLY resorbable/absorbable materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal
  • Patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used

• Recurrence rates: Nasal packing has 50% recurrence rate, significantly higher than surgical options 1

Prevention of Recurrence

Nasal Moisturization

• Apply petroleum jelly or lubricating agents to nasal mucosa once bleeding stops 1, 6
• Regular use of saline nasal sprays to keep nasal mucosa moist 1, 6
• Use humidifiers in dry environments 1

Post-Treatment Instructions

• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after treatment 1
• Avoid picking or rubbing the nose to allow healing 1

When to Escalate Care

Indications for Specialist Referral

• Bleeding refractory to compression, vasoconstrictors, and cautery 1
• Posterior epistaxis (often requires hospitalization and is twice as likely to need packing) 5
• Recurrent bleeding despite appropriate treatment 3
• Need for surgical artery ligation (97% success rate) or endovascular embolization (80% success rate), both with <10% recurrence rates 1, 4

Emergent Evaluation Required

• Active bleeding with airway compromise 2
• Hemodynamic instability 2
• Signs of significant blood loss 2

Documentation and Follow-Up

• Document bleeding duration, frequency, estimated volume, and any prior treatments attempted 2, 6
• Record outcome of intervention within 30 days 2, 6
• Educate patients about preventive measures and indications to seek additional medical care 6