What is the appropriate management for a patient presenting with epistaxis, particularly those with a history of bleeding disorders or anticoagulant use?

Management of Epistaxis

Immediate First-Line Management

For any patient presenting with epistaxis, begin with firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without interruption, with the patient sitting upright and head tilted slightly forward to prevent blood from flowing into the airway. 1

• The patient should breathe through their mouth and spit out blood rather than swallowing it 2
• Compression alone resolves the vast majority of anterior epistaxis cases 2
• Do not check if bleeding has stopped during the compression period, as this interrupts the clotting process 2

If Bleeding Persists After Initial Compression

Apply topical vasoconstrictors (oxymetazoline or phenylephrine spray) directly to the bleeding nostril after clearing any blood clots, then resume firm compression for another 5-10 minutes. 1, 3

• Vasoconstrictor application stops bleeding in 65-75% of cases treated in emergency departments 3, 4, 5
• Clean the nasal cavity of blood clots by suction or gentle nose blowing before applying vasoconstrictors 2
• After vasoconstrictor application, perform anterior rhinoscopy to identify the bleeding source 1, 3

Definitive Treatment Based on Identified Bleeding Site

If a specific bleeding site is identified, perform nasal cautery after anesthetizing the area with topical lidocaine or tetracaine, restricting cautery application only to the active bleeding site. 1, 3

• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 2, 4
• Critical pitfall: Avoid bilateral simultaneous septal cautery as it increases the risk of septal perforation 2
• After cautery, apply petroleum jelly or other moisturizing agents to the nasal mucosa and prescribe regular saline nasal sprays 3, 2

Nasal Packing for Refractory Bleeding

If bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors, proceed to nasal packing. 1, 2

Special Considerations for Patients with Bleeding Disorders or on Anticoagulation

For patients with suspected bleeding disorders or those using anticoagulant or antiplatelet medications, use only resorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal. 1, 6

• In the absence of life-threatening bleeding, initiate first-line treatments (compression, vasoconstrictors, cautery) prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 1, 6
• For patients on warfarin, check INR to evaluate therapeutic range; supratherapeutic levels may require specialty consultation for severe refractory bleeding 3
• Critical pitfall: Do not routinely discontinue anticoagulation for epistaxis that can be controlled with local measures, as the thrombotic risk often outweighs bleeding risk 6

Assessment of Severity and Triage

Distinguish patients requiring prompt management from those who do not based on bleeding duration, hemodynamic stability, and airway patency. 1

• Bleeding duration >30 minutes over a 24-hour period is considered severe epistaxis requiring prompt evaluation 1, 3
• Check for tachycardia, hypotension, orthostatic changes, or syncope—any of these indicate significant blood loss requiring hospital-level care 3
• History of hospitalization for nosebleed, prior blood transfusion for nosebleeds, or >3 recent episodes may indicate need for prompt evaluation 1

Risk Factors to Document

Document all factors that increase the frequency or severity of bleeding in every patient with epistaxis. 1

• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia) 1, 3
• All anticoagulant medications (warfarin, DOACs) and antiplatelet agents (aspirin, clopidogrel) 1, 3
• Prior nasal or sinus surgery 1, 3
• Nasal cannula oxygen or CPAP use 3
• Intranasal medications or illicit drug use 1, 3
• Chronic kidney or liver disease 3

Blood Pressure Management

Do not routinely lower blood pressure acutely during active epistaxis, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia. 3

• Monitor blood pressure, but decisions about control should be based on bleeding severity, inability to control bleeding, individual comorbidities, and risks of blood pressure reduction 3
• Critical pitfall: Aggressive acute blood pressure lowering can cause end-organ ischemia in elderly patients with chronic hypertension 3

Advanced Interventions for Persistent or Recurrent Bleeding

For persistent or recurrent bleeding not controlled by packing or nasal cauterization, evaluate candidacy for surgical arterial ligation or endovascular embolization. 1, 2

• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 2, 4
• Endovascular embolization has an 80% success rate with recurrence rates <10% compared to 50% for nasal packing 2, 4
• Nasal endoscopy should be performed to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology 1, 3

Special Population: 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. 1, 3, 2

Patient Education and Follow-Up

Educate all patients about preventive measures, home treatment, and indications to seek additional medical care. 1

• Apply petroleum jelly to nasal mucosa regularly to maintain moisture 3, 2
• Use saline nasal sprays and humidifiers to keep nasal mucosa moist 3, 2
• Avoid picking or rubbing the nose, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after treatment 2
• Document outcome of intervention within 30 days 1, 6
• For patients who undergo nasal packing, educate about type of packing placed, timing and plan for removal (if not resorbable), postprocedure care, and signs/symptoms warranting prompt reassessment 1