What to do for a patient experiencing epistaxis (nosebleed)?

Management of Epistaxis (Nosebleed)

For an active nosebleed, have the patient lean forward and apply firm, continuous pressure to the soft lower part of the nose for a full 10-15 minutes without checking if bleeding has stopped, as this single intervention resolves the vast majority of cases. 1, 2

Immediate First-Line Management

Initial Positioning and Compression

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or stomach 2
• Instruct the patient to breathe through their mouth and spit out blood rather than swallowing it 2
• Apply firm, continuous pressure by pinching the soft lower third of the nose (not the bony bridge) for a minimum of 10-15 minutes without releasing to check 1, 2
• If bleeding slows but continues, maintain pressure for a full 15 minutes 1
• Compression alone stops the vast majority of anterior epistaxis cases 2, 3

When Compression Alone Fails

After 10-15 minutes of proper compression, if bleeding continues:

• Clear the nasal cavity of blood clots by having the patient gently blow their nose or using suction 4, 3
• Apply topical vasoconstrictor spray: oxymetazoline or phenylephrine, 2 sprays into the bleeding nostril 1, 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 2
• This combination stops bleeding in 65-75% of emergency department cases 2, 5

Important caveat: Vasoconstrictors may cause cardiac or systemic complications in susceptible patients (those with uncontrolled hypertension, coronary artery disease) 2

Advanced Interventions

Indications for Nasal Packing

Proceed to nasal packing if: 2, 3

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors
• Life-threatening bleeding is present
• Posterior bleeding source is suspected
• Patient shows hemodynamic instability

Choice of Packing Material

• For patients on anticoagulants or antiplatelet medications: Use ONLY resorbable/absorbable materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 1, 2, 5
• For patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used 2

Cauterization

• Electrocautery is superior to chemical cauterization when an anterior bleeding site is identified: 14.5% recurrence rate versus 35.1% 2, 5
• Perform anterior rhinoscopy after clot removal to identify the bleeding source 4, 3
• Never perform bilateral simultaneous septal cautery as this significantly increases risk of septal perforation 4

When to Escalate Care

Seek Immediate Emergency Care If: 1

• Bleeding does not stop after 15 minutes of proper compression and vasoconstrictor use
• Patient feels weak, lightheaded, or shows signs of significant blood loss
• Bleeding is severe or persistent
• Active bleeding from nose or mouth despite packing 4
• Hemodynamic instability, fever >101°F, vision changes, shortness of breath, or facial swelling 4

Surgical or Interventional Options

For persistent or recurrent bleeding not controlled by packing or cautery: 2, 4

• Endoscopic sphenopalatine artery ligation: 97% success rate versus 62% for conventional packing 2, 5
• Endovascular embolization: 80% success rate with recurrence rates <10% compared to 50% for nasal packing 2, 5

Prevention and Post-Treatment Care

Immediate Post-Bleeding Care

• Apply petroleum jelly or nasal saline gel to the nasal mucosa 1-3 times daily once bleeding stops to prevent recurrence 1, 4
• Use nasal saline spray regularly throughout the day to keep nasal mucosa moist 1, 2
• Use a humidifier at bedside 1, 4

Activity Restrictions After Cauterization or Packing

For at least one week: 1, 4

• Avoid nose blowing
• Avoid strenuous activity and heavy lifting
• Do not place cotton or tissues in the nose

Long-Term Prevention

• Eliminate digital trauma (nose picking) and vigorous nose blowing 1
• Maintain nasal moisture with saline gels and sprays 1
• Use humidifier at bedside 1, 4

Critical Pitfalls to Avoid

• Do not have the patient tilt their head backward as this causes blood to flow into the airway or stomach 2
• Do not release pressure prematurely to check if bleeding has stopped within the first 10-15 minutes 2, 3
• Do not stop anticoagulants without consulting the prescribing physician, as these medications treat serious conditions like recent MI or stents 1
• If nosebleed is severe in an anticoagulated patient, do not take additional doses until evaluated, but evaluation should not be delayed 1
• Do not delay local control measures while waiting for laboratory results 3

Special Populations

Patients on Anticoagulation

• Do not reverse anticoagulation in hemodynamically stable patients whose bleeding is controlled with local measures 2, 3
• Contact the prescribing clinician promptly, as blood thinners treat serious medical conditions 1, 4
• Use only resorbable packing materials if packing is required 1, 2

Hereditary Hemorrhagic Telangiectasia (HHT)

• Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history 4, 3
• Refer to HHT Center of Excellence for specialized management 1
• Resorbable packing is strongly preferred as removal of non-resorbable packing increases rebleeding risk 1