What is the initial management for a 15-year-old patient presenting with epistaxis (nosebleed)?

Management of Epistaxis in a 15-Year-Old

Begin with firm, continuous compression of the soft lower third of the nose for a full 10-15 minutes while the patient sits upright with head tilted slightly forward, and if bleeding persists after this, apply topical oxymetazoline spray (2 sprays in the bleeding nostril) followed by another 5-10 minutes of compression. 1, 2

Initial First-Line Management

Patient Positioning:

• Seat the patient upright with head tilted slightly forward to prevent blood from flowing into the airway or stomach 1, 2
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 1, 2

Direct Nasal Compression:

• Apply firm, sustained pressure to the soft lower third (soft part) of the nose for at least 10-15 minutes without checking if bleeding has stopped 3, 1, 2
• This compression alone resolves the vast majority of anterior epistaxis cases, which account for over 90% of nosebleeds in this age group 3, 4
• Children presenting with epistaxis have a mean age of 7.5 years, and only 6.9% require procedures beyond simple compression 3

If Bleeding Persists After Initial Compression

Topical Vasoconstrictor Application:

• Clear the nasal cavity of blood clots by having the patient gently blow their nose 2
• Apply oxymetazoline or phenylephrine spray: 2 sprays into the bleeding nostril 1, 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 2
• This approach stops bleeding in 65-75% of cases that don't respond to compression alone 1, 5

FDA-Approved Dosing for Oxymetazoline:

• For patients 6 to under 12 years: 2 or 3 sprays in each nostril, not more often than every 10-12 hours, not exceeding 2 doses in 24 hours 6
• For patients 12 years and older: same dosing applies 6

Prevention of Recurrence

Once Bleeding Has Stopped:

• Apply petroleum jelly or other lubricating agents to the nasal mucosa to prevent recurrence 1, 2
• Recommend regular use of saline nasal sprays to keep the nasal mucosa moist 1, 2
• Consider using a humidifier, especially in dry environments 7
• Instruct the patient to avoid nose picking, vigorous nose-blowing, and nasal manipulation for at least 7-10 days 2

When to Escalate Care

Indications for Advanced Treatment:

• If bleeding does not stop after 15 minutes of continuous pressure with vasoconstrictors 1, 2
• If the patient experiences dizziness due to blood loss 1
• If bleeding is severe (duration >30 minutes over a 24-hour period) 1
• If the patient shows signs of hemodynamic instability such as tachycardia or hypotension 1

Advanced Options (Requiring ENT Specialist):

• Nasal cauterization with silver nitrate or electrocautery if a bleeding site is identified (electrocautery has fewer recurrences: 14.5% vs 35.1% for chemical cauterization) 2, 5
• Nasal packing with resorbable materials (Nasopore, Surgicel, Floseal) if bleeding continues despite compression and vasoconstrictors 2
• Nasal endoscopy to localize the bleeding site, which is successful in 87-93% of cases 2

Common Pitfalls to Avoid

• Insufficient compression time: Compression must be maintained for the full 10-15 minutes without checking if bleeding has stopped prematurely 2
• Incorrect head position: Tilting the head backward allows blood to flow into the airway or stomach 1
• Neglecting prevention: Not treating underlying nasal mucosa dryness leads to recurrent episodes 7
• Bilateral simultaneous septal cautery: This increases the risk of septal perforation and should be avoided 2

Special Considerations for This Age Group

• Epistaxis in adolescents is typically anterior in origin from Kiesselbach's plexus on the nasal septum 3
• Posterior epistaxis accounts for only 5-10% of cases and is more common in older patients 3
• The bimodal age distribution shows peak frequency in children <10 years and in adults, so a 15-year-old falls in the lower-risk category 3
• Only 6.9% of pediatric epistaxis cases require procedures beyond simple measures, with 93.5% of those being simple anterior control 3