From the Guidelines
Epistaxis should be managed by having the person sit down and continuously hold the lower third or soft portion of the nose pinched closed to help the blood clot, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. When evaluating a patient with epistaxis, it is essential to consider the potential causes, which can be remembered using the mnemonic MAPS STAND. This mnemonic breaks down as follows:
- M for Medications (anticoagulants, aspirin, NSAIDs)
- A for Arterial hypertension
- P for Picking/trauma
- S for Septal abnormalities
- S for Systemic diseases (coagulopathies, liver disease)
- T for Tumors
- A for Alcohol/substance abuse
- N for Nasal dryness/environmental factors
- D for Drugs (cocaine) Understanding these causes is crucial for proper management, as treatment should address the underlying cause rather than just stopping the bleeding. For example, if hypertension is causing recurrent nosebleeds, controlling blood pressure would be essential alongside direct measures to stop bleeding, as uncontrolled bleeding can lead to anemia and shock due to blood loss 1. Similarly, if medication-induced, adjusting anticoagulant dosing might be necessary while maintaining therapeutic effect for the original condition. The severity of bleeding can be assessed based on factors such as bleeding duration, history of hospitalization for nosebleed, prior blood transfusion for nosebleeds, or recent episodes of nasal bleeding, as well as patient-related factors like comorbid conditions and signs of acute hypovolemia 1. Nasal pressure alone is the only intervention required in the vast majority of cases, including 20% of cases managed in EDs, and the patient should be instructed to breathe through their mouth and spit out any blood 1.
From the Research
Epistaxis Management
- Epistaxis is a common emergency encountered by primary care physicians, with up to 60% of the general population experiencing it and 6% seeking medical attention 2.
- The evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency 2.
Treatment Options
- Compressive therapy is the first step to controlling anterior epistaxis, with oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 as useful adjuncts 2.
- Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 2.
- Topical therapy and nasal packing can be used if other methods are unsuccessful, with posterior nasal packing often associated with pain and a risk of aspiration if it is dislodged 2.
- Oxymetazoline has been shown to be superior to tranexamic acid and epinephrine-lidocaine in achieving rapid hemostasis and reducing recurrence in epistaxis 3.
- Tranexamic acid has been compared to topical oxymetazoline in the treatment of epistaxis, with one study finding that topical tranexamic acid is more effective than topical oxymetazoline for achievement of hemostasis in anterior epistaxis 4.
- A systematic review of the use of systemic and topical tranexamic acid in epistaxis found that tranexamic acid can be a powerful tool in epistaxis management, with significant benefit in acute epistaxis management and prophylaxis of recurrent epistaxes 5.
Epistaxis Maps and Stands
- There is no direct information available on epistaxis maps and stands in the provided studies.