Epistaxis Treatment
For a patient presenting with epistaxis, immediately apply topical vasoconstrictors (oxymetazoline or phenylephrine) to the bleeding site, which controls bleeding in 65-75% of cases, followed by nasal cautery if bleeding persists, and then apply moisturizing agents to prevent recurrence. 1
Initial Management Algorithm
First-Line: Topical Vasoconstrictors
- Apply oxymetazoline or phenylephrine spray directly to the identified bleeding site 2, 1
- Alternatively, soak cotton pledgets with the vasoconstrictor and insert into the nose, maintaining pressure for 10-15 minutes 2, 1
- These agents achieve hemorrhage control through local vasoconstriction in 65-75% of patients 2, 1
- Epinephrine or cocaine may be used in specialized settings as alternative vasoconstrictors 1
Common pitfall: Do not use vasoconstrictors repeatedly beyond initial treatment, as this can lead to rhinitis medicamentosa, loss of efficacy, and complications including hypertension and excessive nasal dryness 2
Second-Line: Nasal Cautery (If Bleeding Persists)
- Always anesthetize the bleeding site before cautery application using topical lidocaine or tetracaine to minimize patient discomfort 2, 1
- Apply cautery only to the active or suspected bleeding site(s), not broadly 2
- Electrocautery is more effective than chemical cautery (silver nitrate) with fewer recurrences (14.5% vs 35.1%) 2, 3
- Bipolar cautery causes less pain and faster healing compared to monopolar cautery 2
Critical pitfall: Never cauterize both sides of the nasal septum simultaneously, as this significantly increases the risk of septal perforation 2, 1
Third-Line: Nasal Packing (If Cautery Fails)
- Use nasal packing only when vasoconstrictors and cautery have failed 2
- Modern hemostatic materials (Surgicel, Floseal, Spongostan, fibrin glue) are more effective with fewer complications than traditional petroleum jelly gauze 3
- Inflatable anterior nasal balloon packs (Rapid-Rhino) reliably control most anterior nosebleeds 4
- For posterior epistaxis, add a Foley catheter nasopharyngeal balloon pack 4
Adjunctive Therapy: Tranexamic Acid
While the American Academy of Otolaryngology-Head and Neck Surgery notes that additional study is needed to fully understand TXA's role 2, recent high-quality evidence shows:
- Topical TXA is 3.5 times more likely to achieve bleeding cessation at first assessment compared to standard treatment 5
- TXA reduces rebleeding at 24-72 hours by 63% compared to standard practices 5
- TXA promotes hemostasis in 78% of patients versus 35% with oxymetazoline and 31% with nasal packing 3
However, the American Academy of Otolaryngology-Head and Neck Surgery guideline emphasizes that most TXA studies are of moderate quality and primarily from Iran, warranting cautious interpretation until more diverse, high-quality studies are available 2
Prevention of Recurrence
- Apply emollient creams or ointments after bleeding stops to prevent rebleeding 2
- Instruct patients to use nasal saline sprays and humidifiers to keep nasal mucosa moist 2, 1
- Educate patients to avoid picking or rubbing the treated area 1
Special Considerations for Anticoagulated Patients
- Do not routinely discontinue anticoagulation for non-major bleeding, as local control measures are sufficient and stopping increases thrombotic risk 6, 1
- Initiate first-line treatments (vasoconstrictors and cautery) before considering anticoagulation reversal or medication withdrawal 1
- Only discontinue anticoagulants immediately if there is major bleeding with hemodynamic instability or uncontrolled bleeding despite local measures 6
Indications for Urgent Referral or Hospitalization
- Bleeding persisting >30 minutes despite appropriate local measures 6
- Hemodynamic instability or significant blood loss requiring transfusion 6
- Posterior epistaxis requiring specialized balloon placement or arterial ligation 7, 8
- Recurrent bleeding episodes requiring multiple interventions 6
- Patients with significant comorbid conditions or complications of blood loss 7