What is the recommended management for an acute nosebleed (epistaxis), including first‑line measures, cautery, packing, and indications for ENT referral?

Management of Acute Nosebleed (Epistaxis)

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

Initial First-Line Management

Immediate Compression Technique

• Position the patient seated with head tilted forward (not backward) to prevent blood from flowing into the airway or stomach 2
• Apply firm sustained compression to the soft lower third of the nose (not the nasal bridge) for at least 10-15 minutes continuously 1, 2, 3
• The patient should breathe through their mouth and spit out blood rather than swallowing it 2
• Do not release pressure early to check if bleeding has stopped—this is a critical error that prevents clot formation 2
• Compression alone resolves the vast majority of anterior epistaxis cases 1, 2

Adding Topical Vasoconstrictors

If bleeding continues after 10-15 minutes of proper compression:

• First, have the patient blow their nose gently to clear clots 1, 2
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril 1, 2
• Resume firm compression for another 5-10 minutes 2
• Vasoconstrictor application stops bleeding in 65-75% of emergency department cases 2, 4
• May repeat vasoconstrictor application once if needed 1

Common pitfall: The American Heart Association notes that ice packs are not effective for epistaxis and do not significantly change nasal blood flow 2. Despite widespread use, avoid relying on ice application.

Identifying the Bleeding Site

After initial bleeding control:

• Remove any remaining clots by suction or gentle nose blowing 1, 5
• Perform anterior rhinoscopy to identify the bleeding source, focusing on Kiesselbach's plexus on the anterior septum where most bleeds originate 1, 5
• If anterior examination is negative but bleeding continues, consider posterior source—this requires different management 5

Cautery for Identified Bleeding Sites

When a bleeding site is identified:

• Always anesthetize the bleeding site first with topical lidocaine or tetracaine before cautery 1
• Restrict cautery application only to the active or suspected bleeding site—avoid cauterizing healthy tissue 1
• Electrocautery is more effective than chemical cautery (silver nitrate), with recurrence rates of 14.5% versus 35.1% 2, 4
• Critical warning: Avoid bilateral simultaneous septal cautery as this significantly increases risk of septal perforation 2, 5

Nasal Packing Indications

Proceed to nasal packing when:

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors 2, 3
• Life-threatening bleeding is present 1, 3
• Posterior bleeding source is suspected (bleeding from both nostrils or into mouth) 1, 3
• Bleeding site cannot be identified despite compression 1

Packing Material Selection

For patients on anticoagulants or antiplatelet medications: Use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 1, 2, 3

For patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used 2

Post-Packing Care

• Educate patients about the type of packing placed, timing and plan for removal, and warning signs requiring immediate reassessment 2, 3
• Apply nasal saline spray frequently to keep packing moist 2
• Avoid nose blowing, strenuous activity, and heavy lifting for at least 7-10 days 1

Special Consideration: Anticoagulated Patients

In the absence of life-threatening bleeding, initiate first-line treatments (compression, vasoconstrictors, cautery, packing) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications. 1, 3

• Do not routinely discontinue anticoagulation for standard epistaxis 2
• For aspirin in high-risk cardiovascular patients (recent MI or stents), continue aspirin despite epistaxis as survival benefits outweigh bleeding risks 2
• Anticoagulation restart typically occurs within 24-48 hours after confirmed hemostasis 2

Indications for ENT Referral

Refer to otolaryngology when:

• Persistent or recurrent bleeding not controlled by packing or cautery 1, 3, 5
• Recurrent bleeding despite appropriate treatment 2, 5
• Need for nasal endoscopy to identify posterior bleeding source 2, 3, 5
• Evaluation for surgical arterial ligation or endovascular embolization 1, 2, 3

Advanced Interventions

For refractory cases:

• Endoscopic sphenopalatine artery ligation: 97% success rate versus 62% for conventional packing 2, 4
• Endovascular embolization: 80% success rate with recurrence rates <10% compared to 50% for nasal packing 2, 4

Emergent Hospital Evaluation Required When

• Active bleeding with hemodynamic instability (tachycardia, syncope, orthostatic hypotension) 1, 3
• Airway compromise from blood in the oropharynx 3, 5
• Bleeding duration >30 minutes over 24 hours 2, 3, 5
• Bilateral bleeding or bleeding from the mouth 3, 5
• History of hospitalization or transfusion for nosebleeds 3, 5
• More than 3 recent bleeding episodes 2, 5
• Signs of significant blood loss (weakness, lightheadedness) 1

Red Flags for Underlying Pathology

Assess for hereditary hemorrhagic telangiectasia (HHT) in patients with:

• Recurrent bilateral nosebleeds 2, 3, 5
• Family history of recurrent nosebleeds 2, 3
• Examine for nasal and oral mucosal telangiectasias 2, 3
• Refer to HHT Center of Excellence for specialized management 1

Prevention and Patient Education

After bleeding control:

• Apply petroleum jelly or nasal saline gel to nasal mucosa 1-3 times daily to prevent recurrence 1, 2
• Use humidifier at bedside 1
• Avoid digital trauma (nose picking) and vigorous nose blowing 1
• Regular use of saline sprays keeps nasal mucosa moist 2

Documentation Requirements

For patients treated with non-resorbable packing, surgery, or arterial ligation/embolization:

• Document outcome of intervention within 30 days or document transition of care 1, 3, 5