What is the management approach for a patient presenting with epistaxis, considering their potential use of anticoagulant medications and risk for complications such as hypovolemia or airway compromise?

Management of Epistaxis

Initial First-Line Treatment

All patients with epistaxis should be positioned sitting upright with head tilted slightly forward and 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, 3

• The patient should breathe through their mouth and spit out blood rather than swallowing it to prevent nausea and allow assessment of ongoing bleeding 2, 3
• This compression technique alone resolves the vast majority of anterior epistaxis cases (65-75% of cases) 1, 2, 3
• Common pitfall: Insufficient compression time—many patients check too early, which disrupts clot formation and prolongs bleeding 2

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after 10-15 minutes of proper compression:

• Clear the nasal cavity of blood clots by suction or gentle nose blowing 3
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) with 2 sprays into the bleeding nostril 1, 2, 3
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 3
• This approach stops bleeding in 65-75% of cases that don't respond to compression alone 1, 3
• Caution: Vasoconstrictors may cause cardiac or systemic complications in susceptible patients (those with cardiovascular disease or hypertension) 3

Management in Anticoagulated Patients

For patients on anticoagulants or antiplatelet medications, do NOT reverse anticoagulation or discontinue medications unless there is life-threatening bleeding or hemodynamic instability. 2, 3

• Initiate first-line treatments (compression and vasoconstrictors) before considering any medication adjustments 2, 3
• If the patient is on aspirin and at high risk for cardiovascular events (recent MI or stents), continue aspirin despite epistaxis 3
• For NSAIDs: Continue unless bleeding cannot be controlled with local measures; the antiplatelet effects increase bleeding risk but standard epistaxis alone is not an indication to stop 3
• For patients on both NSAIDs and warfarin, expect INR to increase by up to 15% and recognize a three- to sixfold increased risk of bleeding 3

Third-Line Treatment: Nasal Packing

Nasal packing is indicated when:

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors 3
• Life-threatening bleeding is present 3
• A posterior bleeding source is suspected 3

For anticoagulated patients, use ONLY resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal. 2, 3

• For patients without bleeding risk factors, either resorbable or non-resorbable materials may be used 3
• For posterior epistaxis not responding to compression, use posterior nasal packing with a Foley catheter and tranexamic acid-soaked gauze 3

Adjunctive Treatment: Tranexamic Acid

Topical tranexamic acid is probably more effective than other topical agents in stopping bleeding within the first 10 minutes (70% vs 30% success rate). 4

• Oral tranexamic acid given regularly over several days reduces re-bleeding risk from 69% to 49% within 10 days 4
• A single application of topical tranexamic acid may reduce re-bleeding from 66% to 43%, though evidence quality is lower 4
• Recent research (2024) confirms topical tranexamic acid reduces bleeding time and rebleeding compared to anterior nasal packing with gelfoam 5
• No serious adverse effects (seizures, thromboembolic events) were reported in studies, though one patient developed superficial thrombophlebitis 4

Advanced Interventions for Refractory Bleeding

If bleeding persists despite packing or cautery:

• Perform nasal endoscopy to localize the bleeding site (successful in 87-93% of cases) 3
• Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 3
• Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 3

For persistent or recurrent bleeding:

• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 3
• Endovascular embolization has an 80% success rate with recurrence rates less than 10% (compared to 50% for nasal packing) 3

Indications for Urgent Evaluation or ENT Referral

Seek immediate medical attention or ENT consultation if:

• Bleeding does not stop after 15 minutes of continuous pressure 1, 2
• Patient experiences dizziness, tachycardia, or hypotension suggesting hemodynamic instability 1, 2, 3
• Bleeding is severe (duration >30 minutes over a 24-hour period) 1, 2
• Recurrent bleeding despite appropriate treatment 3
• Bilateral recurrent nosebleeds with family history (consider Hereditary Hemorrhagic Telangiectasia) 3

Prevention of Recurrence

Once bleeding has stopped:

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 1, 2, 3
• Recommend regular use of saline nasal sprays to keep nasal mucosa moist 1, 2, 3
• Use a humidifier, especially in dry environments 2, 3
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after packing removal 3

Anticoagulation Resumption

• For anticoagulated patients with controlled bleeding, restart anticoagulation within 24-48 hours after confirmation of hemostasis 3
• Balance the risk of thrombosis against bleeding risk on an individual basis 3

Documentation and Follow-Up

• Document factors increasing bleeding frequency or severity: personal or family history of bleeding disorders, anticoagulant/antiplatelet use, intranasal drug use 3
• Routine follow-up within 30 days is recommended for patients who underwent invasive treatments to assess for complications and recurrent bleeding 3