How to manage epistaxis in adults, including those with hypertension, bleeding disorders, or taking anticoagulants like warfarin (anticoagulant) or aspirin (acetylsalicylic acid)?

How to Stop a Nosebleed

Sit upright with your head tilted slightly forward and apply firm, continuous pressure to the soft lower third of your nose for a full 10-15 minutes without checking if bleeding has stopped—this single intervention resolves the vast majority of nosebleeds. 1, 2

Immediate First-Line Treatment

Proper Positioning and Compression Technique

• Position yourself sitting upright with head tilted slightly forward to prevent blood from flowing into your airway or stomach 3, 2
• Pinch the soft, compressible part of your nose (not the bony bridge) between your thumb and index finger 1, 2
• Apply firm, continuous pressure for 10-15 minutes without releasing to check if bleeding has stopped—premature checking is a common cause of treatment failure 1, 3, 2
• Breathe through your mouth and spit out any blood rather than swallowing it 2

If Bleeding Continues After 15 Minutes

• Clean out blood clots from your nose by gently blowing your nose or using suction 2
• Apply a topical vasoconstrictor spray such as oxymetazoline (Afrin) or phenylephrine—spray 2 times into the bleeding nostril 1, 3
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 3, 2
• These vasoconstrictors stop bleeding in 65-75% of emergency department cases 1

Special Considerations for High-Risk Patients

Patients Taking Anticoagulants (Warfarin, Eliquis, etc.)

Do not stop your anticoagulation medication unless bleeding is life-threatening—local control measures should always be attempted first. 3

• Apply the same compression and vasoconstrictor techniques as above 3
• Seek medical attention even if bleeding stops, as patients on anticoagulants require professional evaluation 3
• Do not take additional doses of your anticoagulant while actively bleeding 3
• Reversal agents should only be used for life-threatening bleeding due to significant stroke risk 3

Patients Taking Aspirin or Other NSAIDs

• Continue aspirin if you have high cardiovascular risk (recent heart attack or stents)—the survival benefits outweigh bleeding risks 2
• Use the same standard compression and vasoconstrictor protocol without stopping the medication unless bleeding cannot be controlled 2
• Most epistaxis resolves with local measures alone, making medication discontinuation unnecessary 2

Patients with Hypertension

• High blood pressure is commonly present during nosebleeds, but this may be due to stress rather than being the cause 4
• Follow the same compression protocol—controlling the bleeding takes priority over blood pressure management 1, 2
• Blood pressure often normalizes once bleeding is controlled and anxiety resolves 4

Prevention of Recurrence

Immediate Post-Bleeding Care

• Apply petroleum jelly or other lubricating ointments to the inside of your nostrils once bleeding stops 1, 3, 2
• Use saline nasal sprays regularly to keep nasal passages moist 1, 2
• Consider using a humidifier, especially in dry environments 1, 3

Ongoing Prevention Strategies

• Avoid picking, rubbing, or blowing your nose vigorously for 7-10 days after a nosebleed 2
• Keep nasal mucosa hydrated with regular saline spray use 2
• Avoid nasal decongestant sprays for prolonged periods, as they can cause rebound dryness 1

When to Seek Medical Attention

Seek immediate medical care if:

• Bleeding does not stop after 15 minutes of continuous, proper compression 3, 2
• You experience lightheadedness, dizziness, or weakness from blood loss 3, 2
• Bleeding is severe (duration >30 minutes over a 24-hour period) 1
• You have signs of significant blood loss such as rapid heartbeat or feeling faint 1, 2
• You are taking anticoagulants, even if bleeding has stopped 3

Advanced Medical Treatments (If Basic Measures Fail)

Professional Interventions

• Nasal cauterization with silver nitrate or electrical cautery after local anesthesia can be performed if a bleeding site is identified 1
• Nasal packing with absorbable materials (Nasopore, Surgicel, Floseal) is used for patients on anticoagulants or when other measures fail 1, 2
• Tranexamic acid (topical or oral) may be used to support clotting without reversing anticoagulation 1, 5

For Severe or Recurrent Cases

• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 2, 6
• Endovascular embolization achieves 80% success with recurrence rates <10% compared to 50% for nasal packing 2, 6

Critical Pitfalls to Avoid

• Insufficient compression time—not maintaining pressure for the full 10-15 minutes is the most common cause of treatment failure 3, 2
• Tilting head backward—this causes blood to flow into the throat and stomach, potentially causing vomiting, and does not help control bleeding 3
• Checking too frequently—releasing pressure repeatedly to see if bleeding has stopped prevents clot formation 3, 2
• Unnecessary anticoagulation reversal—dramatically increases stroke risk and should only occur in life-threatening scenarios 3
• Premature NSAID or aspirin discontinuation—most nosebleeds resolve with local measures alone, and stopping cardiovascular medications can be dangerous 2