What is the management for an elderly woman with uncontrolled epistaxis (nosebleed)?

Management of Uncontrolled Epistaxis in an Elderly Woman

For an elderly woman with uncontrolled epistaxis, immediately position her sitting upright with head tilted slightly forward, apply firm sustained compression to the soft lower nose for a full 10-15 minutes without interruption, and if bleeding persists, apply topical vasoconstrictors followed by nasal packing with resorbable materials—do not discontinue anticoagulants unless life-threatening bleeding occurs. 1, 2

Immediate First-Line Management

Positioning and Direct Compression

• Sit the patient upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed 1, 2
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped, as interrupting compression restarts the process 1, 2
• Have the patient breathe through her mouth and spit out blood rather than swallowing it 2
• This compression alone resolves the vast majority of anterior epistaxis cases 2

Critical pitfall to avoid: Do not have the patient tilt her head backward, as this causes blood to flow into the throat and does not help control bleeding 1

Second-Line Intervention (If Bleeding Continues After 15 Minutes)

Topical Vasoconstrictors

• Clean the nasal cavity of clots by suction or gentle nose blowing 2
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 2
• Vasoconstrictors stop bleeding in 65-75% of emergency department cases 2, 3

Important caveat: Vasoconstrictors may be associated with increased risk of cardiac or systemic complications in susceptible elderly patients, so use with caution in those with cardiovascular disease 2

Third-Line Intervention: Nasal Packing

When to Pack

• Nasal packing is indicated when bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors 2
• Also indicated for life-threatening bleeding or when a posterior bleeding source is suspected 2

Type of Packing for Elderly Patients

• Use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) in elderly patients, especially those on anticoagulants or antiplatelet medications 1, 2
• Resorbable materials reduce trauma during removal and are essential for patients with bleeding disorders or on blood thinners 4, 1

Critical consideration: Elderly patients are at significantly higher risk for severe epistaxis—those aged 76-85 years are 2.37 times more likely and those over 85 years are 3.24 times more likely to present to emergency departments compared to younger patients 1

Management of Anticoagulation

Do Not Stop Blood Thinners

• Anticoagulation or antiplatelet medications should NOT be discontinued in the absence of life-threatening bleeding 1, 2
• Patients who are hemodynamically stable with controlled bleeding using local measures do not require reversal of anticoagulation 2
• The decision to restart anticoagulation should balance thrombosis and bleeding risk, typically occurring within 24-48 hours after hemostasis confirmation 2

Critical pitfall: Premature discontinuation of aspirin in high-risk cardiovascular patients is dangerous, as survival benefits outweigh bleeding risks in patients with recent MI or stents 2

Assessment of Risk Factors

Document Critical Factors

• Personal or family history of bleeding disorders 1, 5
• Current use of anticoagulants or antiplatelet medications 1, 5
• History of hypertension 1
• Hemodynamic stability and ability to protect the airway 1
• Unilateral versus bilateral bleeding pattern (unilateral recurrent bleeding may indicate neoplasm and requires endoscopic evaluation) 5, 2

Advanced Interventions for Persistent or Recurrent Bleeding

Cauterization

• If an anterior bleeding site is identified, electrocautery is more effective than chemical cauterization (14.5% vs 35.1% recurrence rates) 2, 3
• Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 2

Surgical Options

• For persistent or recurrent bleeding not controlled by packing or cautery, evaluate candidacy for surgical arterial ligation or endovascular embolization 4, 1
• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 2, 6
• Endovascular embolization has an 80% success rate with recurrence rates less than 10% compared to 50% for nasal packing 2, 3

Prevention of Recurrence

Post-Treatment Care

• Apply petroleum jelly or moisturizing agents to the nasal mucosa once bleeding stops 1, 2
• Regular use of saline nasal sprays to keep nasal mucosa moist 1, 2
• Use humidifiers in dry environments 1, 2
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after packing removal 2

Patient Education

• Educate about warning signs requiring prompt reassessment 1, 2
• Provide instructions on post-procedure care if packing is placed 4, 1
• Document outcome within 30 days or document transition of care 1, 2

Special Consideration: Hereditary Hemorrhagic Telangiectasia

• Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds, as this may indicate Hereditary Hemorrhagic Telangiectasia requiring specialized management 4, 5