What are the steps to manage a nosebleed in an elderly patient on Dual Antiplatelet Therapy (DAPT) without access to medications?

Stepwise Management of Nosebleed in Elderly Patient on DAPT Without Medications

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 this compression technique alone resolves the vast majority of anterior nosebleeds even in patients on antiplatelet therapy. 1, 2

Step 1: Position the Patient Correctly

• Seat the patient upright with head tilted slightly forward (not backward) to prevent blood from flowing into the airway or stomach 2
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 2
• Critical pitfall to avoid: Tilting the head backward is incorrect and increases aspiration risk 3

Step 2: Apply Proper Nasal Compression

• Pinch the soft lower third of the nose (the cartilaginous portion, not the bony bridge) with firm, continuous pressure 1, 2
• Maintain this pressure for a minimum of 10-15 minutes without releasing to check if bleeding has stopped 1, 2
• Most common error: Releasing pressure prematurely before the full 10-15 minutes leads to treatment failure 4
• This compression alone stops bleeding in the majority of cases, even in patients on anticoagulants or antiplatelet medications 1

Step 3: If Bleeding Continues After 15 Minutes

• Clean the nasal cavity of blood clots by having the patient gently blow their nose or use suction if available 5
• Without topical vasoconstrictors available, reapply firm compression for another 10-15 minutes 1
• The American Academy of Otolaryngology-Head and Neck Surgery notes that while vasoconstrictors stop 65-75% of cases that fail compression alone, compression can still be effective with repeated attempts 2, 6

Step 4: Improvised Nasal Packing (If Bleeding Persists Beyond 30 Minutes)

• If bleeding continues despite 30 minutes of proper compression, nasal packing becomes necessary 2
• For patients on DAPT, use only soft, absorbable materials if available (cotton gauze soaked in water can serve as improvised packing) 1
• Critical consideration: The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends resorbable packing for patients on anticoagulation or antiplatelet medications to reduce trauma during removal 1, 2
• Insert packing gently into the anterior nose, directing it straight back (not upward) 7
• Warning for elderly patients: In patients with cognitive impairment or altered consciousness, packing carries aspiration risk and requires close monitoring 8

Step 5: Seek Emergency Medical Attention If:

• Bleeding does not stop after 15-30 minutes of continuous proper compression 2
• The patient shows signs of hemodynamic instability (dizziness, weakness, lightheadedness, hypotension) 2, 9
• Massive bleeding occurs, which can happen with antiplatelet therapy 9
• Do NOT discontinue DAPT - the American Academy of Otolaryngology-Head and Neck Surgery explicitly states that first-line treatments should be initiated prior to withdrawal of anticoagulation/antiplatelet medications in the absence of life-threatening bleeding 1, 5

Step 6: After Bleeding Stops - Prevention of Recurrence

• Once hemostasis is achieved, apply petroleum jelly (Vaseline) or any available lubricating agent to the anterior nasal septum 2, 5
• Instruct the patient to avoid nose-picking, vigorous nose-blowing, and nasal manipulation for at least 7-10 days 2
• Keep the nasal mucosa moist with regular saline rinses if available 2
• Monitor blood pressure, as uncontrolled hypertension contributed to persistent epistaxis in elderly patients on DAPT 1

Special Considerations for DAPT Patients

• The European Heart Journal case series demonstrates that epistaxis in elderly patients on DAPT may persist for 2-3 weeks despite initial measures 1
• Key principle: Antiplatelet therapy should be continued unless bleeding is life-threatening, as the cardiovascular risks of discontinuation outweigh bleeding risks in most cases 1, 5
• If packing is required and the patient is on DAPT, ensure close follow-up within 24-48 hours for packing removal or assessment 1
• Document the patient's cardiovascular indication for DAPT, as this guides decisions about medication continuation 1

When to Escalate Care

• If bleeding recurs despite proper compression and improvised packing, the patient requires evaluation for endoscopic cauterization, arterial ligation, or embolization 1, 2
• Posterior epistaxis (bleeding that continues despite anterior measures or blood flowing down the throat) requires emergency department evaluation 7