What is the approach to a patient with recurrent self-limited epistaxis (nosebleeds)?

From the Guidelines

For recurrent self-limited nasal bleeds, the most effective approach is to apply direct pressure to the anterior nasal septum (Kiesselbach's plexus) by pinching the soft part of the nose for at least 5 minutes, as recommended by the clinical practice guideline: nosebleed (epistaxis) 1. This approach is supported by the guideline, which emphasizes the importance of direct pressure in controlling bleeding. Additional measures to prevent recurrence include keeping the nasal mucosa moist with saline nasal sprays and gels, using a humidifier, and avoiding digital trauma (nose picking) 1. If bleeds persist, patients may consider over-the-counter options like oxymetazoline nasal spray or consult a medical professional for further evaluation and treatment, including the possibility of surgical arterial ligation or endovascular embolization for persistent or recurrent bleeding not controlled by packing or nasal cauterization 1. It is essential to note that patients on blood thinner medications should promptly check with their clinician if they experience severe or persistent nosebleeds, as these medications can increase the risk of bleeding 1. Overall, the management of recurrent self-limited nasal bleeds should prioritize protecting the fragile nasal mucosa and addressing common causes of epistaxis, with the goal of improving patient outcomes and reducing the risk of complications. Key considerations include:

• Applying direct pressure to the anterior nasal septum for at least 5 minutes to control bleeding
• Keeping the nasal mucosa moist with saline nasal sprays and gels
• Using a humidifier to prevent dryness
• Avoiding digital trauma (nose picking)
• Considering over-the-counter options like oxymetazoline nasal spray for persistent bleeds
• Seeking medical attention if bleeds are severe, persistent, or recurrent, especially in patients on blood thinner medications.

From the Research

Approach to Patient with Recurrent Self-Limited Nasal Bleeds

• The first step in managing a patient with recurrent self-limited nasal bleeds is to assess the patient's vital signs, mental status, and airway patency 2.
• Compressive therapy, such as external pressure and ice packing, can be used as a first aid measure to control the bleeding 3, 2.
• Topical agents like oxymetazoline can be applied to stop the bleeding, with a success rate of 65-75% 3, 4.
• If the bleeding persists, directive nasal cautery using silver nitrate can be used to control localized bleeding or prominent vessels 2.
• Nasal packing can be used if other methods are unsuccessful, but it is often associated with pain and a risk of aspiration if it is dislodged 2.

Treatment Options

• Oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 can be used as adjuncts to compressive therapy 2.
• Tranexamic acid can be used to promote hemostasis, with a success rate of 78% 3.
• Newer hemostatic agents, such as hemostatic gauzes, thrombin matrix, and fibrin glue, can be used in combination with endoscopic methods for more effective management 3.
• Endoscopic ligation of arteries, mainly SPA, can be used for more effective management, with a success rate of 97% 3.

Considerations

• The choice of treatment depends on the patient's history and available resources 3.
• Posterior epistaxis is more likely to require hospitalization and nasal packing, and is associated with a higher risk of complications 2.
• Patients with recurrent self-limited nasal bleeds should be evaluated for any underlying conditions that may be contributing to the bleeding 5.