What is the next action for a patient with a nose bleed and small clots, stable vital signs, and no known bleeding disorders or recent trauma?

Management of Epistaxis with Small Clots and Stable Vital Signs

Apply firm, sustained compression to the soft lower third of the nose for a full 5-10 minutes without interruption while the patient sits upright with head tilted slightly forward. 1, 2

Immediate First-Line Action

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed 2, 3
• Apply firm, continuous compression to the soft lower third of the nose for a minimum of 5 minutes without checking if bleeding has stopped—this is the single most important initial intervention 1, 2, 3
• If bleeding slows but persists, continue holding for a full 15 minutes 1

If Bleeding Persists After 5-10 Minutes

• Clear any blood clots by having the patient blow their nose gently, then perform anterior rhinoscopy to identify the bleeding site 1, 2, 3
• Apply topical vasoconstrictors (oxymetazoline or phenylephrine spray) directly to the bleeding nostril—spray 2 sprays and continue compression for 5 additional minutes 1, 4, 5
  • This achieves hemorrhage control in 65-75% of cases through local vasoconstriction 2, 5
  • May repeat once if needed 1

Definitive Treatment When Bleeding Site Is Identified

• Perform nasal cautery after anesthetizing the area with topical lidocaine or tetracaine if a specific bleeding site is identified 2, 3
• Restrict cautery application only to the active bleeding site to minimize risk of septal perforation 2, 3
• Avoid bilateral septal cautery as this can cause septal perforation 2

If Bleeding Cannot Be Controlled

• Proceed to nasal packing if bleeding continues despite compression and vasoconstrictors 2, 3
• Use resorbable packing materials (Nasopore, Surgicel, Floseal) as first choice 2, 3

Post-Treatment Management

• Apply petroleum jelly or other moisturizing agents to the nasal mucosa and prescribe regular saline nasal sprays 3-4 times daily to maintain mucosal moisture 2, 6
• Instruct the patient to avoid nose blowing, strenuous activity, heavy lifting, or placing cotton/tissues in the nose for at least one week 1, 6
• Use a humidifier at bedside 1, 6

Critical Pitfall to Avoid

• Do not tilt the head backward—this is a common error that causes blood to flow into the airway and be swallowed 1, 4
• Do not interrupt compression prematurely to check if bleeding has stopped—this prevents clot formation and prolongs bleeding 2, 3

Documentation Requirements

• Document the presence and location of clots, whether active bleeding is present, risk factors (anticoagulation, hypertension, prior nasal surgery), interventions performed, and whether the bleeding site was identified 6, 3
• Arrange follow-up within 30 days to assess outcome 2, 6