How should I manage a 79-year-old woman with a three‑day persistent epistaxis who is taking low‑dose aspirin, rosuvastatin (Crestor), and alprazolam (Xanax)?

Management of 3-Day Persistent Epistaxis in a 79-Year-Old Woman on Aspirin

This patient requires immediate medical evaluation today—either in an urgent care clinic with ENT capabilities or an emergency department—because bleeding lasting 3 days far exceeds the 30-minute threshold that defines severe epistaxis requiring prompt intervention. 1

Immediate Assessment Priority

This 79-year-old woman meets multiple criteria for severe epistaxis requiring urgent evaluation:

• Bleeding duration >30 minutes over 24 hours is considered severe and warrants prompt medical attention 1
• Three days of persistent bleeding indicates failure of natural hemostasis and requires professional intervention 2
• Aspirin use significantly increases epistaxis severity, recurrence rates, and need for surgical intervention 3
• Advanced age (79 years) increases risk of posterior bleeding sources and complications 4

Critical pitfall to avoid: Do not attempt prolonged home management or delay seeking care—this duration of bleeding requires direct visualization and intervention by a clinician with appropriate equipment. 1, 2

First-Line Treatment Protocol (To Be Performed by Clinician)

Step 1: Initial Compression and Vasoconstriction

• 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
• Patient should sit upright with head tilted slightly forward, breathe through mouth, and spit out blood rather than swallow it 2
• After compression, clean nasal cavity of clots by suction or gentle nose blowing 2
• Apply topical vasoconstrictor (oxymetazoline or phenylephrine spray—2 sprays into bleeding nostril), which stops bleeding in 65-75% of cases 2
• Resume firm compression for another 5-10 minutes after vasoconstrictor application 2

Step 2: Identify Bleeding Source

• Perform anterior rhinoscopy after clot removal to identify the bleeding source 1, 2
• If anterior rhinoscopy fails to identify the source or bleeding is difficult to control, perform nasal endoscopy to examine the nasal cavity and nasopharynx 1
• Nasal endoscopy localizes the bleeding site in 87-93% of cases 2

Step 3: Definitive Treatment Based on Findings

If a specific bleeding site is identified:

• Perform nasal cautery (preferably electrocautery, which has 14.5% recurrence vs. 35.1% for chemical cautery) 2
• Anesthetize the bleeding site with topical lidocaine 1
• Restrict cautery application only to the active bleeding site 1
• Never perform bilateral septal cautery simultaneously—this increases septal perforation risk 2

If bleeding persists despite compression and vasoconstrictors:

• Proceed to nasal packing 1, 2
• Use only resorbable/absorbable packing materials (Nasopore, Surgicel, or Floseal) because she is on aspirin—this avoids trauma during removal 1, 2, 5
• Non-resorbable packing should NOT be used in patients on antiplatelet medications 1, 5

Critical Management Principle for Aspirin

DO NOT discontinue aspirin for this epistaxis. 1, 5, 6

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends initiating first-line local treatments (compression, vasoconstrictors, cautery, packing) prior to withdrawal of antiplatelet medications in the absence of life-threatening bleeding 1, 5
• Aspirin should only be discontinued if bleeding is truly life-threatening (massive hemorrhage requiring transfusion, hemodynamic instability, or airway compromise) 5
• If she takes aspirin for cardiovascular protection (history of MI, stents, stroke prevention), continuing aspirin is essential—the survival benefits outweigh bleeding risks 2

Common pitfall: Premature aspirin discontinuation is a frequent error; most epistaxis resolves with local measures alone without stopping antiplatelet therapy. 2, 5

Advanced Interventions if Initial Measures Fail

If bleeding continues despite proper compression, vasoconstrictors, and packing:

• Consider topical tranexamic acid (TXA) application—this stops bleeding faster (6.7 vs. 11.5 minutes) and reduces recurrence (6% vs. 20%) compared to standard packing in patients on antiplatelet drugs 1, 7
• Evaluate for surgical arterial ligation or endovascular embolization—these have <10% recurrence rates compared to 50% for nasal packing alone 2, 5
• Endoscopic sphenopalatine artery ligation has 97% success rate vs. 62% for conventional packing 2

Prevention of Recurrence (Critical for Long-Term Management)

Aggressive nasal mucosal moisturization is the cornerstone of preventing recurrent epistaxis in patients on aspirin: 5

• Apply petroleum jelly to the anterior nasal septum 1-3 times daily, particularly before bedtime 2, 5
• Use saline nasal sprays regularly throughout the day to maintain mucosal moisture 2, 5
• Consider bedside humidification during sleep, especially in dry climates or winter months 5
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days after treatment 2

When to Escalate to ENT Specialist

Refer to otolaryngology if: 2, 5, 6

• Bleeding persists despite nasal packing
• Recurrent bleeding occurs despite appropriate treatment and preventive measures
• Bilateral recurrent nosebleeds (consider hereditary hemorrhagic telangiectasia screening) 1, 5
• Need for surgical ligation or embolization evaluation 1, 5

Notes on Other Medications

• Crestor (rosuvastatin): Does not contribute to bleeding risk—continue without modification [@general medical knowledge@]
• Xanax (alprazolam): Does not affect hemostasis—continue without modification [@general medical knowledge@]