What are the management guidelines for a patient presenting with epistaxis, considering potential underlying causes and recurrent episodes?

Epistaxis Management Guidelines

Initial Assessment and Triage

At first contact, immediately distinguish patients requiring prompt management from those who do not by assessing for active bleeding, hemodynamic instability (tachycardia, hypotension, syncope), airway compromise from blood in the oropharynx, or bleeding duration exceeding 30 minutes over 24 hours. 1, 2

Key factors indicating need for urgent intervention: 1, 3

• Active bleeding with signs of hemodynamic compromise
• Bleeding duration >30 minutes in 24 hours
• Pallor, dizziness, or altered mental status suggesting significant blood loss
• History of anticoagulation or bleeding disorders

First-Line Treatment: Nasal Compression

Apply firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without interruption while the patient sits upright with head tilted slightly forward. 1, 2, 4

Critical technique details: 2, 3

• Position: sitting upright, head tilted forward (not backward) to prevent blood entering airway or stomach
• Location: compress the soft cartilaginous part of the nose, not the bony bridge
• Duration: minimum 10-15 minutes continuously without checking if bleeding stopped
• Patient should breathe through mouth and spit out blood rather than swallowing

Common pitfall: Insufficient compression time—checking too early disrupts clot formation and prolongs bleeding. 5

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after adequate compression, apply topical vasoconstrictors: 1, 2, 6

• Oxymetazoline or phenylephrine spray: 2 sprays directly into the bleeding nostril 2, 5
• Remove blood clots first (by suction or gentle nose blowing) to allow direct mucosal contact 1
• Continue compression for additional 5 minutes after application 5
• This approach resolves 65-75% of cases that don't respond to compression alone 2, 6

Examination and Bleeding Site Identification

Perform anterior rhinoscopy after removing blood clots to identify the bleeding source. 1, 3

Equipment needed: 1

• Nasal speculum and headlamp (or otoscope for young children)
• Suction to clear clots and secretions

For recurrent unilateral epistaxis despite prior treatment, or difficult-to-control bleeding, perform nasal endoscopy or refer to a specialist who can. 1, 3

Red flags requiring endoscopy: 1, 3

• Recurrent bleeding despite packing or cautery
• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes (concern for mass lesion)
• Adolescent males with profuse unilateral bleeding (concern for juvenile nasopharyngeal angiofibroma)

Definitive Treatment: Cautery

When a specific bleeding site is identified: 3, 4

• Apply topical anesthetic (lidocaine or tetracaine) to the bleeding site 3
• Perform silver nitrate cautery restricted only to the active bleeding site 3, 4
• Never perform bilateral septal cautery simultaneously—this causes septal perforation 1, 3

Nasal Packing

If bleeding continues despite compression, vasoconstrictors, and cautery: 1, 5

• Use resorbable packing materials (Nasopore, Surgicel, Floseal) as first choice 3
• For patients on anticoagulants, antiplatelet agents, or with suspected bleeding disorders, resorbable packing is mandatory 1, 5

Packing education requirements: 1

• Type of packing placed
• Timing and plan for removal (if non-resorbable)
• Post-procedure care instructions
• When to seek additional care

Special Population: Anticoagulated Patients

Initiate first-line local hemostatic treatments (compression, vasoconstrictors, cautery) before considering transfusion, anticoagulation reversal, or medication withdrawal. 5, 3

For patients on warfarin with severe refractory bleeding: 3

• Check INR to evaluate therapeutic range
• Supratherapeutic levels may require specialty consultation or reversal agents

Do not routinely discontinue anticoagulation for isolated epistaxis episodes—local measures are usually sufficient. 2, 5

Blood Pressure Management

Do not routinely lower blood pressure acutely during active epistaxis. 3

Critical rationale: 3

• Excessive blood pressure reduction can cause or worsen renal, cerebral, or coronary ischemia
• Particularly dangerous in elderly patients with chronic hypertension
• Monitor blood pressure but base treatment decisions on bleeding severity, inability to control bleeding, and individual comorbidities

Prevention of Recurrence

Once bleeding controlled: 2, 5, 3

• Apply petroleum jelly or other lubricating agents to nasal mucosa 2, 3
• Prescribe regular saline nasal sprays to maintain mucosal moisture 2, 3
• Recommend humidifier use in dry environments 5

Documentation Requirements

Document factors that increase frequency or severity of bleeding: 1, 3

• Anticoagulant/antiplatelet medications (warfarin, aspirin, clopidogrel, DOACs)
• Prior nasal or sinus surgery
• Nasal cannula oxygen or CPAP use
• Intranasal medications or illicit drug use
• Personal or family history of bleeding disorders
• Chronic kidney or liver disease
• Hypertension

Indications for Specialist Referral

Refer to ENT or evaluate for surgical intervention when: 1

• Persistent or recurrent bleeding not controlled by packing or cauterization
• Candidacy assessment needed for surgical arterial ligation or endovascular embolization

Assess for hereditary hemorrhagic telangiectasia (HHT) in patients with: 1, 3

• History of recurrent bilateral nosebleeds
• Family history of recurrent nosebleeds
• Presence of nasal or oral mucosal telangiectasias

Follow-Up

Arrange follow-up to assess treatment effectiveness, especially when treatments are ineffective or recurrent bleeding is documented. 1, 3

This allows for: 1

• Further diagnostic testing when needed
• Assessment of preventive measures
• Evaluation for underlying pathology in refractory cases