What is the recommended initial and subsequent management of epistaxis, including first‑aid measures, cautery, packing, and special considerations for patients on anticoagulants or with coagulopathy?

Epistaxis Management

Immediate First-Line Treatment

Position the patient sitting 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 during this time. 1, 2, 3

• The patient should breathe through their mouth and spit out blood rather than swallowing it to prevent nausea and allow assessment of ongoing bleeding 1, 3
• This compression technique alone resolves the vast majority of anterior epistaxis cases 1, 2, 3
• Critical pitfall: Most patients and healthcare providers incorrectly compress the nasal bridge rather than the soft lower third of the nose, which is ineffective 4, 5

If Bleeding Persists After Initial Compression

Clear any blood clots from the nasal cavity by suction or gentle nose blowing, then apply a topical vasoconstrictor spray (oxymetazoline or phenylephrine) with 2 sprays into the bleeding nostril, and resume firm compression for another 5-10 minutes. 1, 3

• This approach resolves 65-75% of epistaxis cases presenting to emergency departments 1, 2, 6
• After clot removal, perform anterior rhinoscopy to identify the bleeding site 2, 3
• Important caveat: Vasoconstrictors may be associated with increased risk of cardiac or systemic complications in susceptible patients 3

Cautery (When Bleeding Site is Identified)

Nasal cautery is more effective than nasal packing when a bleeding site can be clearly visualized. 2

• Electrocautery is superior to chemical cauterization, with recurrence rates of 14.5% versus 35.1% respectively 3, 6
• Proper anesthetization of the site is required before cautery 2
• Critical warning: Avoid bilateral simultaneous septal cautery as it increases the risk of septal perforation 2, 3

Nasal Packing (If Above Measures Fail)

Nasal packing is indicated when bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors, for life-threatening bleeding, or when a posterior bleeding source is suspected. 3

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 3
• Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) are more effective with fewer complications than traditional materials 6

Post-Packing Care:

• Educate the patient about the type of packing placed, timing and plan for removal (if not resorbable), and warning signs requiring prompt reassessment 1, 2
• Apply nasal saline spray frequently throughout the day to keep packing moist 3
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after packing removal 3

Special Considerations for Anticoagulated Patients

Initiate first-line treatments (compression, vasoconstrictors, cautery, packing) before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulant/antiplatelet medications. 1, 2, 3

• Anticoagulation should not be reversed in hemodynamically stable patients with controlled bleeding using local measures 3
• For aspirin specifically: If the patient is at high risk of cardiovascular events (recent MI or stents), aspirin should be continued despite epistaxis as survival benefits outweigh bleeding risks 3
• The decision to restart anticoagulation should be made individually, typically within 24-48 hours after confirmation of hemostasis 3
• Important interaction: NSAIDs combined with anticoagulants increase GI and mucosal bleeding risk three- to sixfold 3

When to Escalate Care

Seek immediate medical attention if: 1, 2, 3

• Bleeding persists after 15 minutes of continuous proper compression
• Bleeding duration exceeds 30 minutes over a 24-hour period
• Patient shows signs of hemodynamic instability (tachycardia, hypotension) or becomes lightheaded
• Active bleeding from nose or mouth despite packing
• Epistaxis due to trauma with signs of brain injury, nasal deformity, or facial fracture

Advanced Interventions for Persistent or Recurrent Bleeding

Perform nasal endoscopy when bleeding is difficult to control, there is concern for unrecognized pathology, or patient has recurrent bleeding despite prior treatment with packing or cautery. 2, 3

• Nasal endoscopy localizes the bleeding site in 87-93% of cases 3
• For persistent bleeding not controlled by packing or cauterization: Evaluate candidacy for surgical arterial ligation or endovascular embolization 1, 2, 3

Surgical Options Success Rates:

• Endoscopic sphenopalatine artery ligation: 97% success rate versus 62% for conventional packing 3, 6
• Endovascular embolization: 80% success rate with recurrence rates less than 10% compared to 50% for nasal packing 3, 6
• Endoscopic cauterization is more effective than ligation 6

Prevention and Long-Term Management

Apply petroleum jelly or nasal emollients regularly to the nasal mucosa to prevent mucosal dryness and recurrence. 1, 2, 3

• Use saline nasal sprays regularly to keep nasal mucosa moist 1, 3
• Recommend humidifiers, especially in dry environments 1, 2
• Document factors increasing bleeding frequency or severity: personal/family history of bleeding disorders, anticoagulant/antiplatelet use, intranasal drug use 1, 2, 3

Screen for Hereditary Hemorrhagic Telangiectasia:

• Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds 1, 2, 3

Patient Education

Educate patients and caregivers about home treatment techniques, preventive measures, and indications to seek additional medical care. 1, 2

• Provide written instructions backed up by verbal advice, which improves recall from 8% to 50% 7
• Many patients (40%) cannot recall a single first-aid measure for epistaxis without education 7
• Document outcome of intervention within 30 days for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 2, 3

What NOT to Do

Ice packs are NOT recommended: Current evidence does not support the use of ice packs (applied to forehead, neck, or intraorally) as a first aid intervention for acute epistaxis, as they do not significantly change nasal blood flow or volume 8, 3