What is the best approach to managing epistaxis in an elderly patient?

Managing Epistaxis in Elderly Patients

Elderly patients with nosebleeds require immediate firm compression of the soft lower third of the nose for 10-15 minutes as first-line treatment, followed by topical vasoconstrictors if bleeding persists, with special attention to their higher risk of posterior bleeding, anticoagulation use, and significant comorbidities that increase mortality risk. 1, 2

Why Elderly Patients Are High-Risk

Elderly patients face substantially elevated risks with epistaxis:

• Patients aged 76-85 years are 2.37 times more likely to present to emergency departments for epistaxis than those under 65, and those over 85 are 3.24 times more likely 1
• 30-day all-cause mortality rate is 3.4% in elderly epistaxis patients, making this a potentially life-threatening condition 1
• Posterior epistaxis (5-10% of cases) is significantly more common in elderly patients and more difficult to control 1
• 45% of hospitalized epistaxis patients have systemic illnesses contributing to bleeding, including hypertension (33%), anticoagulation use (15%), and coagulation disorders 1

Immediate Management Algorithm

Step 1: Assess Severity and Triage (First 60 Seconds)

Determine if the patient requires emergent versus routine management based on these critical factors: 2, 3

Emergent evaluation required if:

• Active bleeding with hemodynamic instability (tachycardia, syncope, orthostatic hypotension) 1, 2, 3
• Airway compromise from blood in oropharynx 2, 3
• Bleeding duration >30 minutes over 24 hours 1, 3
• Bleeding from both nostrils or mouth (suggests posterior source) 1, 3

Document immediately:

• Anticoagulant/antiplatelet medications (present in 15% of elderly epistaxis patients) 1, 3
• Comorbidities: hypertension, cardiovascular disease, renal disease, liver disease, anemia, bleeding disorders 3
• History of prior epistaxis requiring hospitalization or transfusion 1, 3

Step 2: First-Line Treatment - Nasal Compression

Have the patient sit upright with head tilted slightly forward (not backward) and apply firm, continuous pressure by pinching the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped. 1, 2

Critical technique details:

• Patient should breathe through mouth and spit out blood rather than swallowing it 2
• The most common error is releasing pressure prematurely to check if bleeding stopped—this leads to treatment failure 2
• Compression alone resolves the vast majority of anterior epistaxis cases 1, 2

Step 3: Topical Vasoconstrictors (If Compression Fails)

If bleeding continues after 10-15 minutes of proper compression, clean the nasal cavity of clots and apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril, then resume firm compression for another 5-10 minutes. 2, 3

• Vasoconstrictor application stops bleeding in 65-75% of cases that don't respond to compression alone 2, 4, 5
• Caution: May be associated with increased risk of cardiac or systemic complications in susceptible elderly patients with cardiovascular disease 2

Step 4: Visualization and Cautery

After removing blood clots by suction or gentle nose blowing, perform anterior rhinoscopy to identify the bleeding source. 3

If a bleeding site is clearly visible on the anterior septum:

• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization with silver nitrate (35.1%) 2, 5
• Never perform bilateral simultaneous septal cautery—this increases risk of septal perforation 2

Step 5: Nasal Packing (If Bleeding Persists After 15-30 Minutes)

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

Critical packing decisions for elderly patients:

For patients on anticoagulants or antiplatelet medications (15% of elderly epistaxis patients):

• Use ONLY resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 2, 3
• Never use non-resorbable materials in anticoagulated patients 2, 3

For patients without bleeding risk factors:

• Either resorbable or non-resorbable materials may be used 2

Post-packing management:

• Document type of packing placed, timing and plan for removal, and warning signs requiring immediate reassessment 2
• Instruct patient to apply nasal saline spray frequently throughout the day to keep packing moist 2
• Provide antibiotics for patients with nasal packing (standard practice to prevent toxic shock syndrome) 6, 7

Special Considerations for Anticoagulated Elderly Patients

Do NOT routinely reverse anticoagulation in hemodynamically stable patients with controlled bleeding using local measures. 2

Key principles:

• Anticoagulation should only be reversed for life-threatening bleeding 2
• Decision to restart anticoagulation should be made individually, balancing thrombosis versus bleeding risk, typically within 24-48 hours after confirmed hemostasis 2
• For aspirin specifically: If patient is at high risk of cardiovascular events (recent MI or stents), aspirin should be continued despite epistaxis 2

When to Escalate Treatment

Consider nasal endoscopy if: 2, 3

• Bleeding is difficult to control despite appropriate treatment
• Recurrent bleeding occurs despite prior treatment
• Anterior rhinoscopy fails to identify the source
• Concern exists for unrecognized pathology (tumors, vascular malformations)

Nasal endoscopy localizes the bleeding site in 87-93% of cases 2

Evaluate for surgical arterial ligation or endovascular embolization if: 2

• Persistent or recurrent bleeding not controlled by packing or cautery
• Endoscopic sphenopalatine artery ligation has 97% success rate versus 62% for conventional packing 2, 5
• Endovascular embolization has 80% success rate with recurrence rates <10% compared to 50% for nasal packing 2, 5

Prevention of Recurrence

Once bleeding stops, apply petroleum jelly or other lubricating agents to the anterior nasal septum to prevent recurrence. 2

Instruct patients to:

• Use saline nasal sprays regularly to keep nasal mucosa moist 2
• Use humidifiers, especially in dry environments 2
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days 2

Red Flags Requiring Immediate Specialist Referral

Refer to otolaryngology or emergency department for: 2, 4

• Posterior epistaxis (more common in elderly, often requires hospitalization) 1, 6, 4
• Active bleeding from nose or mouth despite packing 2
• Hemodynamic instability, fever >101°F, vision changes, shortness of breath, or facial swelling 2
• Recurrent bilateral nosebleeds with family history (screen for hereditary hemorrhagic telangiectasia) 2

Common Pitfalls to Avoid

• Releasing compression before full 10-15 minutes—the most common cause of treatment failure 2
• Using non-resorbable packing in anticoagulated patients 2, 3
• Stopping aspirin in high-risk cardiovascular patients—survival benefits outweigh bleeding risks 2
• Bilateral simultaneous septal cautery—increases septal perforation risk 2
• Failing to document anticoagulation status and comorbidities that predict severity 3