What is the most effective management approach for a patient with a nosebleed, particularly those with a history of bleeding disorders or taking anticoagulant medications?

How to Treat Nosebleed

For active nosebleeds, sit upright with head tilted slightly forward and apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped. 1, 2

Immediate First-Line Management

Positioning and Compression

• Position the patient sitting 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 (not the bony bridge) of the nose for at least 10-15 minutes without interruption 1, 2, 3
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 3
• Compression alone resolves the vast majority of anterior epistaxis cases 1, 3

If Bleeding Persists After Initial Compression

• Clear the nasal cavity of blood clots by gentle nose blowing or suction 3
• Apply a topical vasoconstrictor: spray 2 sprays of oxymetazoline or phenylephrine into the bleeding nostril 1, 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 3
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 2

Special Considerations for High-Risk Patients

Patients on Anticoagulants or Antiplatelet Medications

• Document the use of anticoagulant or antiplatelet medications as a risk factor 1
• Initiate first-line treatments (compression and vasoconstrictors) before considering transfusion, reversal of anticoagulation, or medication withdrawal 1, 4
• Do not discontinue blood thinners without consulting the prescribing clinician, as these medications treat serious medical conditions 1
• If nosebleed is severe, hold additional doses of blood thinner until evaluated, but evaluation should not be delayed 1
• If nasal packing becomes necessary, use only resorbable/absorbable materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 1, 3, 4

Patients with Bleeding Disorders

• Document personal or family history of bleeding disorders as this increases frequency and severity of bleeding 1
• Use resorbable packing materials if nasal packing is required 1

Advanced Interventions When First-Line Measures Fail

Nasal Packing Indications

• Apply nasal packing if bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors 3
• Also indicated for life-threatening bleeding or when a posterior bleeding source is suspected 1, 3
• For patients NOT on anticoagulants, either resorbable or non-resorbable materials may be used 3

Identification of Bleeding Source

• Perform anterior rhinoscopy to identify the bleeding source after clot removal 1, 3
• Nasal endoscopy should be performed for recurrent bleeding despite prior treatment with packing or cautery, or for recurrent unilateral bleeding 1
• Endoscopy localizes the bleeding site in 87-93% of cases 3

Cauterization

• When cautery is chosen, anesthetize the bleeding site and restrict application only to the active or suspected site(s) 1
• Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 3
• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 3

Surgical Options for Refractory Cases

• For persistent or recurrent bleeding not controlled by packing or cautery, evaluate candidacy for surgical arterial ligation or endovascular embolization 1, 3
• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 3
• Endovascular embolization has an 80% success rate with recurrence rates less than 10% compared to 50% for nasal packing 3

Prevention of Recurrence

Immediate Post-Bleeding Care

• Once bleeding stops, apply moisturizing or lubricating agents such as petroleum jelly to the nasal mucosa to prevent recurrence 1, 2, 3
• Use saline nasal sprays 1-3 times daily to keep the nasal mucosa moist 1, 2, 4

Long-Term Prevention

• Eliminate contributing factors: avoid nose picking and vigorous nose blowing 1
• Use a humidifier at bedside, especially in dry environments 1, 4
• After cauterization, avoid nose blowing, strenuous activity, heavy lifting, or placing cotton/tissues in the nose for at least one week 1

When to Seek Emergency Care

Seek immediate medical attention if: 1, 2

• Bleeding does not stop after 15 minutes of continuous proper compression
• The patient experiences dizziness, weakness, or lightheadedness from blood loss
• Bleeding is severe (duration >30 minutes over a 24-hour period)
• Signs of hemodynamic instability such as tachycardia or hypotension develop
• Active bleeding from nose or mouth despite packing, fever over 101°F, vision changes, shortness of breath, or facial swelling occur 3

Follow-Up and Documentation

• Document the outcome of intervention within 30 days for patients treated with nonresorbable packing, surgery, or arterial ligation/embolization 1
• Educate patients about warning signs requiring reassessment and proper post-procedure care 1
• For patients with nasal packing, ensure understanding of the type placed, timing of removal (if non-resorbable), and signs of complications 1

Common Pitfalls to Avoid

• Insufficient compression time: Must maintain pressure for full 10-15 minutes without checking 3, 4
• Compressing the bony bridge instead of the soft lower third of the nose 3
• Premature discontinuation of anticoagulants in high-risk cardiovascular patients 3
• Neglecting prevention measures leading to recurrent episodes 4
• Bilateral septal cautery increasing perforation risk 3