What is the best course of treatment for a patient experiencing massive epistaxis (nosebleed)?

Management of Massive Epistaxis

For massive epistaxis, immediately apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes while assessing hemodynamic stability, followed by topical vasoconstrictors if bleeding persists, then nasal packing with resorbable materials, and finally consider endoscopic sphenopalatine artery ligation or endovascular embolization for refractory cases. 1, 2

Immediate Assessment and Stabilization

Triage for severity first by evaluating for signs of hemodynamic instability including tachycardia, syncope, orthostatic hypotension, or altered mental status. 1, 2 Massive epistaxis is defined by:

• Bleeding duration >30 minutes over 24 hours 1
• Bilateral bleeding or blood from the mouth (suggesting posterior source) 1, 2
• History of prior hospitalization or transfusion for epistaxis 1
• Signs of acute hypovolemia 1

Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach. 3, 2 Have the patient breathe through their mouth and spit out blood rather than swallowing it. 3, 2

First-Line Treatment: Nasal Compression

Apply firm, continuous pressure by pinching the soft lower third of the nose for a minimum of 10-15 minutes without checking if bleeding has stopped. 1, 2 This single intervention stops the vast majority of anterior epistaxis cases. 1, 2

Critical pitfall: Premature release of pressure before the full 10-15 minutes is the most common error leading to treatment failure. 2, 4

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after proper compression:

• Clear the nasal cavity of blood clots by suction or gentle nose blowing 2
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) with 2 sprays into the bleeding nostril 3, 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 2

This approach resolves 65-75% of epistaxis cases that don't respond to compression alone. 3, 2, 5

Third-Line Treatment: Nasal Packing

Nasal packing is indicated when:

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors 2
• Life-threatening bleeding is present 2
• A posterior bleeding source is suspected 2

For patients on anticoagulants or antiplatelet medications, use ONLY resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal. 1, 3, 2 For patients without bleeding risk factors, either resorbable or non-resorbable materials may be used. 2

Important caveat: In the absence of life-threatening bleeding, initiate first-line treatments before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications. 1, 3

Fourth-Line Treatment: Surgical or Interventional Management

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

Endoscopic Sphenopalatine Artery Ligation

• Success rate: 97% compared to 62% for conventional packing 2, 5
• More effective than endoscopic cauterization alone 5
• Recurrence rate <10% 2

Endovascular Embolization

• Success rate: 80% with comparable efficacy to surgical methods 2, 5
• Recurrence rate <10% compared to 50% for nasal packing 2, 5
• Consider for patients who are poor surgical candidates 5

Critical Management Considerations

Perform anterior rhinoscopy after clot removal to identify the bleeding source. 1, 2 If the source cannot be identified or bleeding is difficult to control, perform nasal endoscopy to examine the nasal cavity and nasopharynx, which localizes the bleeding site in 87-93% of cases. 1, 2

Avoid bilateral simultaneous septal cautery as it increases the risk of septal perforation. 2

Prevention of Recurrence

Once bleeding is controlled:

• Apply petroleum jelly or other moisturizing/lubricating agents to the nasal mucosa to prevent recurrence 1, 3, 2
• Recommend regular use of saline nasal sprays to keep nasal mucosa moist 3, 2
• Use a humidifier in dry environments 3

Patient Education and Follow-Up

Educate patients about:

• Type of packing placed (if applicable) 1
• Timing and plan for removal of packing (if not resorbable) 1
• Post-procedure care including avoidance of nasal manipulation and vigorous nose-blowing for 7-10 days 2
• Signs requiring prompt reassessment: bleeding >15 minutes despite compression, dizziness, hemodynamic instability 3, 2

Document the outcome of intervention within 30 days or document transition of care. 1, 2

Special Populations

For patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds, assess for nasal and oral mucosal telangiectasias to evaluate for hereditary hemorrhagic telangiectasia (HHT), which requires specialized management. 2