What is the initial management for a patient presenting with epistaxis, considering potential complicating factors such as bleeding disorders or anticoagulant use?

Initial Management of Epistaxis

For patients presenting with epistaxis, immediately apply firm, sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped, regardless of anticoagulant use or bleeding disorders—this single intervention resolves the vast majority of cases and should never be bypassed. 1

Immediate First-Line Treatment

Patient Positioning and Compression Technique

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or being swallowed 1, 2
• Apply continuous, firm pressure by pinching the soft cartilaginous lower third of the nose (not the bony bridge) for a minimum of 10-15 minutes 1, 3
• Critical pitfall: Do NOT release pressure prematurely to check if bleeding has stopped—this is the most common error leading to treatment failure 2, 3
• Have the patient breathe through their mouth and spit out any blood rather than swallowing it 2, 3

Second-Line Treatment: Topical Vasoconstrictors

If bleeding persists after proper compression:

• Clear the nasal cavity of blood clots by gentle nose blowing or suction 3
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine): 2 sprays into the bleeding nostril 1, 2, 3
• Resume firm compression for another 5-10 minutes 3
• This approach stops bleeding in 65-75% of cases that don't respond to compression alone 1, 2, 4

Third-Line Treatment: Identification and Cautery

If bleeding continues despite compression and vasoconstrictors:

• Perform anterior rhinoscopy after clot removal to identify the bleeding source 1, 3
• If a discrete bleeding site is visible, apply local anesthesia (topical lidocaine or tetracaine) 1
• Perform cautery restricted only to the active or suspected bleeding site 1
• Electrocautery is more effective than chemical cautery (silver nitrate) with fewer recurrences (14.5% vs 35.1%) 1, 5
• Critical warning: Never perform bilateral simultaneous septal cautery—this significantly increases risk of septal perforation 3

Fourth-Line Treatment: Nasal Packing

Indications for nasal packing 3:

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors
• Life-threatening bleeding
• Posterior bleeding source suspected

Packing Material Selection Based on Patient Factors

• For patients on anticoagulants or antiplatelet medications: Use ONLY resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 1, 3
• For patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used 3
• Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) are more effective with fewer complications than traditional packing 5

Critical Management Principle for Anticoagulated Patients

In the absence of life-threatening bleeding, initiate all first-line treatments (compression, vasoconstrictors, cautery, packing) BEFORE considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 1

This approach is essential because:

• Most epistaxis resolves with local measures alone, even in anticoagulated patients 3
• Stopping anticoagulation in high-risk cardiovascular patients (recent MI, stents) carries greater mortality risk than the bleeding itself 3
• Hemodynamically stable patients with controlled bleeding do not require anticoagulation reversal 3

Assessment of Severity and Triage

Factors indicating need for prompt/emergent management 1:

• Bleeding duration >30 minutes over 24 hours
• Bleeding from both nostrils or mouth (suggests posterior source)
• Signs of hemodynamic instability: tachycardia, syncope, orthostatic hypotension, dizziness, weakness
• History of hospitalization for epistaxis or prior transfusion

• 3 recent episodes of nasal bleeding

Prevention of Recurrence

Once bleeding is controlled 1, 2, 3:

• Apply petroleum jelly or other moisturizing/lubricating agents to the anterior nasal septum
• Recommend regular use of saline nasal sprays to keep nasal mucosa moist
• Use humidifiers in dry environments
• Avoid nose picking, vigorous nose-blowing, and nasal decongestants for 7-10 days

When to Escalate Care

Refer to otolaryngology or consider advanced interventions if 1, 3:

• Bleeding persists despite proper nasal packing
• Recurrent bleeding despite appropriate treatment
• Posterior bleeding source identified on nasal endoscopy
• Consider surgical arterial ligation (97% success rate) or endovascular embolization (80% success rate) for refractory cases 3, 5

Special Consideration: Hereditary Hemorrhagic Telangiectasia

Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds—this may indicate HHT requiring specialized management 1, 3

Documentation Requirements

Document within 30 days 1:

• Outcome of intervention
• Factors increasing bleeding frequency or severity (bleeding disorders, anticoagulant use, intranasal drug use)
• Transition of care if patient does not follow up