How to manage a patient with epistaxis, considering potential underlying conditions such as bleeding disorders or anticoagulant use?

Management of Epistaxis

Begin immediate treatment with firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes while the patient sits upright with head tilted slightly forward, and if bleeding persists after proper compression, apply topical vasoconstrictors (oxymetazoline or phenylephrine) followed by additional compression. 1, 2

Initial Assessment and Triage

Assess severity immediately to determine the appropriate care setting: 1

• Severe epistaxis requiring emergency evaluation includes bleeding duration >30 minutes over 24 hours, signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension), bilateral bleeding, bleeding from the mouth, or history of hospitalization/transfusion for epistaxis 1
• Minor bleeding without airway compromise or hemodynamic issues can be managed in an ambulatory setting with appropriate expertise and supplies 1
• High-risk comorbidities that warrant prompt evaluation include hypertension, cardiopulmonary disease, anemia, bleeding disorders, liver or kidney disease, and anticoagulant/antiplatelet use 1

Step 1: Immediate First-Line Treatment

Position and compress: 2, 3

• Sit the patient upright with head tilted slightly forward to prevent blood from entering the airway or stomach 2, 3
• Apply firm, continuous pressure to the soft lower third of the nose for 10-15 minutes without checking if bleeding has stopped 1, 2, 3
• Patient should breathe through mouth and spit out blood rather than swallowing it 2, 3

This compression alone resolves the vast majority of anterior epistaxis cases. 3

Step 2: Topical Vasoconstrictors (If Bleeding Persists)

If bleeding continues after proper compression: 2, 3

• Clear the nasal cavity of blood clots by suction or gentle nose blowing 3
• Apply oxymetazoline or phenylephrine spray (2 sprays in the bleeding nostril) 2, 3
• Resume firm compression for another 5-10 minutes 2, 3
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 2, 4

Caution: Vasoconstrictors may be associated with increased risk of cardiac or systemic complications in susceptible patients 3

Step 3: Identify the Bleeding Source

After initial control measures: 1, 3

• Perform anterior rhinoscopy to identify the bleeding source after clot removal 1, 3
• If anterior rhinoscopy fails to identify the source or bleeding recurs, perform or refer for nasal endoscopy, which localizes the bleeding site in 87-93% of cases 1, 3

Step 4: Cauterization (If Source Identified)

When a discrete bleeding site is identified: 1

• Anesthetize the bleeding site before cauterization 1
• Restrict cautery application only to the active or suspected site(s) of bleeding 1
• Electrocautery is superior to chemical cauterization with fewer recurrences (14.5% vs 35.1%) 3, 4
• Never perform bilateral simultaneous septal cautery as this increases risk of septal perforation 3

Step 5: Nasal Packing (If Bleeding Continues)

Indications for nasal packing: 1, 3

• Ongoing active bleeding despite compression, vasoconstrictors, and cautery 1
• Life-threatening bleeding 3
• Posterior bleeding source 3

Critical distinction for anticoagulated patients: 1, 5, 3

• For patients on anticoagulants or antiplatelet medications: Use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal 5, 3, 4
• For patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used 3

For posterior epistaxis: Consider posterior nasal packing with a Foley catheter and tranexamic acid-soaked gauze 3

Special Considerations for Anticoagulated Patients

Do not routinely reverse anticoagulation: 1, 5, 3

• In the absence of life-threatening bleeding, initiate first-line treatments before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications 1, 5
• Patients who are hemodynamically stable with controlled bleeding using local measures do not require reversal of anticoagulation 3
• Decision to restart anticoagulation should balance thrombosis and bleeding risk, typically within 24-48 hours after confirmed hemostasis 3

Prevention of Recurrence

Once bleeding has stopped: 2, 5, 3

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 2, 5, 3
• Recommend regular use of saline nasal sprays to keep nasal mucosa moist 2, 5, 3
• Consider humidifier use, especially in dry environments 5
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after packing removal 3

Advanced Treatment Options (Refractory Cases)

For persistent or recurrent bleeding not controlled by packing or cautery: 3

• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 3, 4
• Endovascular embolization has an 80% success rate with recurrence rates <10% compared to 50% for nasal packing 3, 4
• Both surgical ligation and embolization have comparable efficacy and lower recurrence rates than packing 3, 4

When to Refer to ENT Specialist

Refer for specialist evaluation when: 2, 3

• Bleeding persists despite initial measures 2
• Recurrent bleeding despite appropriate treatment 3
• Posterior epistaxis requiring advanced management 3
• Consideration for surgical arterial ligation or endovascular embolization 3
• Suspected hereditary hemorrhagic telangiectasia (recurrent bilateral nosebleeds, family history, mucosal telangiectasias) 3

Common Pitfalls to Avoid

• Insufficient compression time: Compression must be maintained for the full 10-15 minutes without checking if bleeding has stopped 5
• Incorrect compression site: Pressure must be applied to the soft lower third of the nose, not the nasal bridge 1, 2, 3
• Premature anticoagulation reversal: Most epistaxis resolves with local measures alone without need for reversal 5, 3
• Using non-resorbable packing in anticoagulated patients: This increases trauma risk during removal 5, 3
• Neglecting prevention: Not treating underlying nasal mucosa dryness leads to recurrent episodes 5

Documentation and Follow-Up

• Document bleeding duration, severity, hemodynamic status, anticoagulant/antiplatelet use, personal or family history of bleeding disorders, and intranasal drug use 3
• Document outcome of intervention within 30 days or document transition of care 1
• Routine follow-up is recommended for patients who underwent invasive treatments to assess for complications and recurrent bleeding 3