How to manage a patient with epistaxis (nosebleed) and left ear pain in an urgent care setting without cauterization availability?

Management of Epistaxis in Urgent Care Without Cauterization

In an urgent care setting without cauterization capability, treat active epistaxis with firm sustained compression to the lower third of the nose for 10-15 minutes, followed by topical vasoconstrictors (oxymetazoline or phenylephrine), and if bleeding persists, proceed directly to nasal packing with resorbable materials. 1

Immediate First-Line Management

Step 1: Position and Compress

• Seat the patient upright with head tilted slightly forward to prevent blood from entering the airway or stomach 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 1, 2
• Instruct the patient to breathe through their mouth and spit out blood rather than swallowing it 1, 2
• Compression alone resolves the vast majority of anterior epistaxis cases 1, 2

Critical Pitfall: Do not release pressure prematurely to check for bleeding cessation—this disrupts clot formation and prolongs bleeding 2

Step 2: Topical Vasoconstrictors (If Compression Fails)

If bleeding continues after 15 minutes of proper compression:

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

Important Caveat: Vasoconstrictors may be associated with increased risk of cardiac or systemic complications in susceptible patients (elderly, hypertensive, cardiac disease) 2

Step 3: Nasal Packing (When Vasoconstrictors Fail)

Indications for nasal packing in urgent care: 1, 2

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

Packing Material Selection:

• For patients on anticoagulants or antiplatelet medications: Use ONLY resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal 1, 2
• For patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used 2

Patient Education After Packing: 1

• Inform patient about the type of packing placed
• Provide timing and plan for removal (if not resorbable)
• Explain post-procedure care: avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7-10 days 2
• Specify warning signs requiring prompt reassessment (recurrent bleeding, fever, severe pain)

Addressing the Left Ear Pain

The left ear pain in this patient likely represents referred pain from nasal manipulation or increased pressure from the epistaxis itself, rather than a separate pathology requiring immediate intervention. However:

• Document the ear pain and assess for signs of acute otitis media or eustachian tube dysfunction
• If ear pain persists after epistaxis control, consider otoscopic examination
• Ear pain alone does not change the epistaxis management algorithm

Prevention of Recurrence

Once bleeding has stopped: 1, 2

• Apply petroleum jelly or lubricating agents to the nasal mucosa to prevent recurrence
• Prescribe regular saline nasal sprays to keep nasal mucosa moist
• Recommend humidifier use, especially in dry environments

When to Transfer to Emergency Department

Transfer immediately if: 1

• Signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension)
• Airway compromise from blood
• Bleeding duration >30 minutes over a 24-hour period despite interventions
• Suspected posterior epistaxis not controlled by anterior packing
• Patient on anticoagulants with uncontrolled bleeding despite resorbable packing

Special Considerations for Anticoagulated Patients

• Do NOT discontinue anticoagulation or antiplatelet medications in the absence of life-threatening bleeding 1, 2
• Initiate first-line treatments (compression, vasoconstrictors, packing) prior to considering reversal of anticoagulation 1
• Use resorbable packing materials exclusively in this population 1
• Patients on anticoagulants should seek care from a healthcare professional unless bleeding has completely stopped 1

Documentation Requirements

• Document severity of bleeding (duration, volume, bilateral vs unilateral) 1
• Record risk factors: anticoagulant/antiplatelet use, hypertension, bleeding disorders, prior epistaxis requiring hospitalization 1, 2
• Document intervention performed and patient response 1
• Arrange follow-up within 30 days or document transition of care 1