How to manage a patient with hypertensive nasal bleed?

Management of Hypertensive Nasal Bleed

Do not routinely lower blood pressure acutely in patients with hypertensive epistaxis, as excessive reduction may cause renal, cerebral, or coronary ischemia. 1, 2

Blood Pressure Management in Epistaxis

The relationship between hypertension and epistaxis is associative, not causal—no causal link has been established despite hypertension prevalence ranging from 24-64% in epistaxis patients. 2, 3

Blood pressure should be monitored but decisions about acute control must be based on:

• Severity of bleeding and inability to control with local measures 1, 2
• Individual patient comorbidities 1, 2
• Potential risks of rapid blood pressure reduction (end-organ ischemia) 1, 2

In the absence of hypertensive emergency, interventions to acutely reduce blood pressure can have adverse effects including worsening renal, cerebral, or coronary ischemia. 1

Immediate Management Algorithm

Step 1: Patient Positioning and Direct Compression

Position the patient sitting upright with head tilted slightly forward to prevent blood aspiration or swallowing. 2, 4

Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped. 1, 2, 4 This compression technique alone stops bleeding in the majority of cases. 2, 4

Step 2: Remove Clots and Identify Bleeding Site

After initial compression, remove blood clots by gentle nose blowing or suction to visualize the bleeding site. 1, 2, 4

Perform anterior rhinoscopy to identify the source of bleeding. 1, 4

Step 3: Topical Vasoconstrictors (If Bleeding Persists)

Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril, then resume firm compression for another 5-10 minutes. 1, 2, 4

These vasoconstrictors control 65-75% of nosebleeds that don't respond to compression alone. 1, 2, 4

Important caveat: While package warnings caution against use in hypertensive patients, a randomized controlled trial found intranasal vasoconstrictors did not significantly increase blood pressure in patients without cardiovascular disease. 5 Given clinical necessity in active epistaxis, these warnings are commonly overridden. 5

Step 4: Nasal Cautery (If Bleeding Site Identified)

When a bleeding site is clearly visible, perform nasal cautery—bipolar electrocautery is preferable to chemical cautery (silver nitrate) as it is more effective with fewer recurrences (14.5% vs 35.1%). 1, 2, 4

Critical pitfall: Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation. 1, 4

Step 5: Nasal Packing (If Above Measures Fail)

Nasal packing is indicated when bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors, for life-threatening bleeding, or when a posterior bleeding source is suspected. 2, 4

Use resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) rather than non-resorbable materials to reduce trauma during removal, especially important in hypertensive patients who may be on anticoagulants. 2, 4

Risk Factor Assessment

Obtain a directed history including: 1, 2

• Onset, duration, and frequency of bleeding 1, 2
• Other bleeding sites or bruising 1
• Current medications, especially anticoagulants/antiplatelets 1, 2
• Intranasal medications (corticosteroids increase risk 2.74-fold) 1, 2
• Nasal oxygen or CPAP use 1, 2
• Prior nasal surgery 1, 2

Anticoagulation Management

Check INR in patients on warfarin to evaluate therapeutic range. 1, 2 Supratherapeutic INR may require specialty consultation, medication discontinuation, or reversal agents if bleeding is severe and refractory to initial therapies. 1, 2

Do not routinely discontinue anticoagulants/antiplatelets for nosebleeds unless bleeding is severe and refractory to initial therapies. 2 The decision to reverse anticoagulation should balance thrombotic risk against bleeding severity. 4

Prevention of Recurrence

Once bleeding is controlled, apply petroleum jelly or other moisturizing agents to the anterior nasal septum. 2, 4

Recommend regular use of saline nasal sprays and humidifiers to keep nasal mucosa moist and prevent recurrence. 2, 4

Educate patients to avoid: 2

• Digital trauma (nose picking) 2
• Vigorous nose blowing 2
• Trauma to the healing area 2

Consider cessation of intranasal corticosteroids in patients with recurrent or severe nosebleeds. 1

Advanced Management for Refractory Cases

For persistent or recurrent bleeding not controlled by packing or cautery, evaluate candidacy for surgical arterial ligation or endovascular embolization. 4

Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing, with recurrence rates less than 10% versus 50% for nasal packing. 4

Document outcomes within 30 days for patients treated with nonresorbable packing, surgery, or arterial procedures. 2