What is the treatment for nose bleeding (epistaxis) in a patient with dengue fever?

Treatment of Nose Bleeding in Dengue

In dengue patients with epistaxis, apply the same standard epistaxis management protocol as for any patient: firm continuous pressure to the soft lower nose for 10-15 minutes, followed by topical vasoconstrictors if needed, with special attention to avoiding NSAIDs and monitoring for signs of severe dengue hemorrhagic fever. 1

Initial Management Approach

The treatment of epistaxis in dengue follows standard epistaxis protocols, as there is no dengue-specific modification required for local bleeding control 1, 2:

• Have the patient sit upright with head slightly forward to prevent blood from flowing into the airway or being swallowed 1
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped prematurely 1
• Instruct the patient to breathe through their mouth and spit out blood rather than swallowing it 1

Adjunctive Measures if Compression Fails

If bleeding persists after 15 minutes of proper compression 1, 2:

• Clear the nasal cavity of blood clots by gentle suction or nose blowing 1
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) - 2 sprays into the bleeding nostril 1, 2
• Resume firm compression for another 5-10 minutes after vasoconstrictor application 1
• This approach stops bleeding in 65-75% of emergency department cases 1

Critical Dengue-Specific Considerations

While the local management is standard, dengue patients require heightened vigilance 3, 4:

• Avoid NSAIDs completely - use acetaminophen only for fever control, as NSAIDs worsen platelet dysfunction and bleeding risk 3
• Monitor for signs of dengue hemorrhagic fever (DHF): rising hematocrit, falling platelet count, and evidence of plasma leakage 3
• Epistaxis in dengue may signal progression to DHF/DSS - particularly when accompanied by other hemorrhagic manifestations like petechiae, gum bleeding, or gastrointestinal bleeding 4
• Severe gastrointestinal bleeding carries a poor prognosis in dengue - 10 of 15 deaths in one series had GI bleeding 4

When to Escalate Care

Dengue patients with epistaxis require closer monitoring than typical epistaxis cases 5, 3:

• If bleeding does not stop after 15 minutes of continuous pressure with vasoconstrictors, consider nasal packing 1
• For patients with thrombocytopenia (common in dengue), use only resorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal 1
• Monitor vital signs closely - tachycardia, hypotension, or signs of shock require immediate fluid resuscitation 3
• Check serial hematocrit and platelet counts - rising hematocrit with falling platelets indicates plasma leakage and DHF 3

Prevention of Recurrence

Once bleeding is controlled 1:

• Apply petroleum jelly or nasal lubricants to the nasal mucosa to prevent recurrence 1
• Use saline nasal sprays regularly to keep mucosa moist 1
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days 1

Common Pitfalls to Avoid

• Insufficient compression time - must maintain pressure for full 10-15 minutes without checking 1
• Using NSAIDs for fever - this significantly worsens bleeding risk in dengue 3
• Failing to recognize DHF progression - epistaxis may be an early warning sign requiring hospitalization and IV fluid management 3, 4
• Bilateral simultaneous septal cautery - increases risk of septal perforation if cautery becomes necessary 1

Indications for Hospitalization

Dengue patients with epistaxis should be hospitalized if 3:

• Bleeding persists despite proper local measures
• Signs of hemoconcentration (rising hematocrit >20% from baseline)
• Severe thrombocytopenia (platelets <50,000/μL with active bleeding)
• Evidence of plasma leakage (pleural effusion, ascites, hypoalbuminemia)
• Hemodynamic instability (hypotension, tachycardia, altered mental status)

The key distinction is that while the local treatment of epistaxis is identical to non-dengue patients, the systemic implications and monitoring requirements are vastly different due to the risk of progression to life-threatening DHF/DSS 3, 4.