What is the treatment for a patient presenting with a nosebleed, potentially due to underlying conditions such as hypertension or a bleeding disorder?

Nosebleed Treatment

For acute nosebleed, immediately apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without interruption, with the patient sitting upright and head tilted slightly forward—this is the single most important first-line intervention that controls bleeding in the majority of cases. 1, 2

Immediate Management Algorithm

Step 1: Proper Positioning and Compression (0-15 minutes)

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed 2, 3
• Apply firm, continuous compression to the soft lower third (not the bony bridge) of the nose for a full 10-15 minutes without checking if bleeding has stopped—insufficient compression time is the most common error 2, 4
• Have the patient breathe through the mouth and spit out blood rather than swallowing it 4
• This simple maneuver alone stops the majority of nosebleeds and should never be skipped 1, 2

Step 2: If Bleeding Persists After 15 Minutes of Compression

• Apply topical vasoconstrictors (oxymetazoline or phenylephrine nasal spray) directly to the bleeding site after clearing any blood clots 2, 3, 5
• These vasoconstrictors stop bleeding in 65-75% of cases when combined with continued compression for 5 minutes 2, 6
• Perform anterior rhinoscopy after removing blood clots to identify the specific bleeding site 1, 3

Step 3: Definitive Treatment Based on Identified Bleeding Site

• If a specific bleeding site is identified, perform nasal cautery after anesthetizing the area with topical lidocaine or tetracaine—this is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 3, 6
• Restrict cautery application only to the active bleeding site to minimize risk of septal perforation 3
• Never perform bilateral septal cautery as this significantly increases the risk of septal perforation 3

Step 4: If Bleeding Site Cannot Be Identified or Bleeding Persists

• Proceed to nasal packing using resorbable materials (Nasopore, Surgicel, Floseal) as first choice over non-absorbable materials 3, 4
• Newer hemostatic materials like thrombin matrix (Floseal), hemostatic gauzes (Surgicel), and gelatin sponge (Spongostan) are more effective with fewer complications than traditional petroleum jelly gauze or PVA tampons 6

Special Considerations for Underlying Conditions

Hypertension Management

• Do NOT routinely lower blood pressure acutely during active epistaxis—excessive reduction can cause or worsen renal, cerebral, or coronary ischemia, particularly in elderly patients with chronic hypertension 3
• Monitor blood pressure but base treatment decisions on bleeding severity, inability to control bleeding, individual comorbidities, and risks of blood pressure reduction 3
• Systolic blood pressure is independently associated with persistent epistaxis (odds ratio 1.03 per mmHg increase), but acute aggressive lowering causes more harm than benefit 3, 7

Patients on Anticoagulation or Antiplatelet Agents

• Continue anticoagulation in the absence of life-threatening bleeding and initiate first-line local hemostatic treatments rather than reversing anticoagulation 4
• Check INR if patient is on warfarin—supratherapeutic levels may require specialty consultation, medication discontinuation, or reversal agents only for severe refractory bleeding 3
• Use resorbable nasal packing materials if packing becomes necessary in anticoagulated patients 3, 4
• Do not routinely discontinue anticoagulation as the thromboembolic risk typically outweighs the bleeding risk when proper local hemostatic measures are applied 4

Bleeding Disorders

• Document personal or family history of bleeding disorders (von Willebrand disease, hemophilia), but do not delay first-line local hemostatic measures 3
• Consider tranexamic acid as an adjunct—oral tranexamic acid given regularly over several days reduces re-bleeding risk from 69% to 49% (RR 0.73) compared to placebo 8
• Topical tranexamic acid may be effective but evidence is limited to a single study 8

Prevention of Recurrence

• Apply petroleum jelly or other moisturizing agents to the nasal mucosa and prescribe regular saline nasal sprays—daily nasal moisturization resolves up to 65% of recurrent cases 2, 3, 4
• Use a humidifier in the bedroom, particularly during winter months or in dry climates 2, 4
• Avoid nose picking, keep fingernails trimmed, and teach proper gentle nose-blowing techniques 2
• Avoid nose blowing, strenuous activity, and heavy lifting for at least one week after any intervention 2

Indications for Emergency Department Transfer or ENT Referral

• Bleeding duration >20-30 minutes despite proper compression and vasoconstrictors 2, 3
• Signs of hemodynamic instability: tachycardia, hypotension, orthostatic changes, syncope, or pallor suggesting significant blood loss 3
• Recurrent nosebleeds (more than once weekly) despite preventative measures 2, 4
• Posterior epistaxis suspected (more common in elderly, more difficult to control, higher hospitalization risk) 6, 9
• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes suggesting possible mass lesion 3

Advanced Interventions for Refractory Cases

• Endoscopic sphenopalatine artery ligation is more effective than conventional nasal packing (97% vs 62% success rate) for posterior epistaxis 6
• Endoscopic cauterization is more effective than arterial ligation for identified bleeding sites 6
• Interventional radiology embolization using gelatin sponge, foam, PVA, or coils has 80% success rate with comparable efficacy to surgical methods for intractable cases 6

Critical Pitfalls to Avoid

• Do not check if bleeding has stopped before completing the full 10-15 minutes of compression—premature checking is the most common cause of treatment failure 4
• Do not place tissues or cotton inside the nose as they can be aspirated 2
• Do not aggressively lower blood pressure acutely as this causes end-organ ischemia in elderly patients 3
• Do not overlook anticoagulation status—check INR if on warfarin but do not routinely reverse unless bleeding is life-threatening 3, 4
• Do not perform bilateral septal cautery due to perforation risk 3

Follow-Up

• Arrange follow-up within 30 days to assess outcome and document response to intervention 3, 4
• Continue nasal moisturization even after bleeding has resolved to prevent recurrence 2, 3
• Reassess if bleeding recurs despite preventive measures and consider ENT referral 4