What is the best approach to manage bleeding from Kiesselbach's plexus in a patient, considering potential underlying conditions such as bleeding disorders, hypertension, or previous nasal trauma?

Management of Kiesselbach's Plexus Bleeding

For bleeding from Kiesselbach's plexus, apply firm sustained compression to the soft lower third of the nose for at least 5 minutes, followed by topical vasoconstrictors (oxymetazoline or phenylephrine), and then nasal cautery if a specific bleeding site is identified—this stepwise approach controls 65-75% of cases and prevents recurrence when followed by nasal moisturizers. 1

Immediate First-Line Management

Patient positioning and compression are critical first steps:

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed 2
• Apply firm, continuous compression to the soft lower third of the nose for a full 5-10 minutes without interruption or checking if bleeding has stopped 1, 2
• This simple maneuver alone resolves the majority of anterior epistaxis cases 3

If Bleeding Persists After Initial Compression

Proceed immediately to visualization and topical vasoconstrictors:

• Perform anterior rhinoscopy after removing any blood clots to identify the bleeding site 1, 2
• Apply topical vasoconstrictors (oxymetazoline or phenylephrine spray) directly to the identified bleeding site, which achieves hemorrhage control in 65-75% of cases 1, 2
• These agents can be applied via spray or on a cotton pledget 1

Definitive Treatment: Nasal Cautery

When a specific bleeding site is identified:

• Anesthetize the area first with topical lidocaine or tetracaine 1, 2
• Perform nasal cautery restricted only to the active or suspected bleeding site 1, 2
• Critical pitfall to avoid: Never perform bilateral septal cautery, as this significantly increases the risk of septal perforation 2

Special Considerations for Underlying Conditions

Hypertension

• Do NOT routinely lower blood pressure acutely during active epistaxis, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia, particularly in elderly patients with chronic hypertension 2
• Monitor blood pressure, but decisions about control should be based on bleeding severity, inability to control bleeding, individual comorbidities, and risks of blood pressure reduction 2
• Note that elevated systolic blood pressure is independently associated with persistent epistaxis from Kiesselbach's area (odds ratio 1.03 per mmHg increase), but acute aggressive lowering is contraindicated 2, 4

Bleeding Disorders

• Document personal or family history of bleeding disorders (von Willebrand disease, hemophilia) 2, 5
• First-line local hemostatic measures should NOT be delayed while investigating coagulopathy 2
• Consider nasal packing with resorbable materials for patients with known bleeding disorders 2

Anticoagulation/Antiplatelet Therapy

• For warfarin: Check INR to evaluate therapeutic range; supratherapeutic levels may require specialty consultation, medication discontinuation, or reversal agents only for severe refractory bleeding 2
• For antiplatelet agents (aspirin, clopidogrel): These can cause persistent epistaxis but should not be immediately discontinued—initiate first-line treatments first 2, 5
• Critical pitfall: Do not overlook anticoagulation status, but also do not reflexively discontinue these medications without considering thrombotic risks 2

Previous Nasal Trauma

• Document history of prior nasal or sinus surgery, as post-surgical changes can affect one side of the nasal cavity and contribute to bleeding 2
• Previous trauma may have created vulnerable vessels or septal abnormalities 5

When to Consider Nasal Endoscopy

Even when bleeding from Kiesselbach's plexus is identified and controlled, nasal endoscopy may still be indicated in specific circumstances:

• Bleeding was unusually difficult to control 1
• Clinical symptoms or signs suggest additional bleeding sites or intranasal pathology 1
• Recurrent bleeding despite prior treatment 2, 5
• Unilateral recurrent epistaxis (may indicate neoplasm and requires endoscopic evaluation) 2, 5
• The French Society of Otorhinolaryngology recommends nasal endoscopy in evaluation of all patients with epistaxis, even when ectasia of Kiesselbach's plexus is seen 1
• Nasal endoscopy can localize the bleeding site in 87-93% of cases 1

Post-Treatment Prevention

After bleeding is controlled:

• Apply petroleum jelly or other moisturizing/lubricating agents to the nasal mucosa 1, 2
• Prescribe regular saline nasal sprays to maintain mucosal moisture 2, 3
• Use humidifiers to prevent mucosal dryness 3
• These measures help prevent recurrent bleeding at the treated site 1

Red Flags Requiring Emergency Department Evaluation

Transfer to emergency department if:

• Bleeding duration exceeds 30 minutes in a 24-hour period 2, 3
• Signs of hemodynamic instability (tachycardia, hypotension, orthostatic changes, syncope, pallor) 2
• Bleeding persists despite compression, vasoconstrictors, and cautery 2
• Patient may require posterior packing, endoscopy, or advanced interventions 2

Critical Pitfalls to Avoid

• Never aggressively lower blood pressure acutely during active epistaxis—this can cause end-organ ischemia 2
• Never perform bilateral septal cautery—restrict to the active bleeding site only 2
• Never overlook unilateral recurrent bleeding—this may indicate neoplasm and requires endoscopic evaluation 2, 5
• Never immediately discontinue anticoagulation—initiate first-line local treatments before considering medication adjustments 2, 5
• Never miss hereditary hemorrhagic telangiectasia (HHT)—assess for history of recurrent bilateral epistaxis or family history of recurrent nosebleeds, as this requires specialized management 2, 5