What is the recommended urgent care management for a patient presenting with epistaxis?

Urgent Care Management of Epistaxis

For a patient presenting with active epistaxis in urgent care, immediately position them sitting upright with head tilted slightly forward and apply firm, continuous compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped. 1

Immediate First-Line Management

Patient Positioning and Direct Compression

• Seat the patient upright with head tilted forward (not backward) to prevent blood from entering the airway or causing vomiting if swallowed 1
• Instruct the patient to breathe through their mouth and spit out blood rather than swallowing it 1
• Apply firm, sustained pressure to the soft lower third of the nose for a minimum of 10-15 minutes continuously—this can be performed by the patient, caregiver, or clinician 1, 2
• Critical pitfall: Do not release pressure intermittently to check if bleeding has stopped, as this disrupts clot formation 2
• Compression alone resolves the vast majority of anterior epistaxis cases, including 20% of emergency department presentations 1

Baseline Assessment During Compression

• Obtain baseline blood pressure measurement, as approximately 33% of epistaxis patients have underlying hypertension 2
• Document medication history, particularly anticoagulants, antiplatelets, and NSAIDs 1, 2

Second-Line Treatment (If Bleeding Persists After 15 Minutes)

Topical Vasoconstrictor Application

• Clear the nasal cavity of blood clots by suction or gentle nose blowing 2
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril 2
• Resume firm compression for another 5-10 minutes after vasoconstrictor application 2
• Evidence: Vasoconstrictors stop bleeding in 65-75% of emergency department cases 2, 3, 4

Anterior Rhinoscopy

• After clot removal, perform anterior rhinoscopy to identify the bleeding source 1, 2
• If a focal bleeding site is identified, proceed to cautery 1, 2

Third-Line Treatment: Cautery (When Bleeding Site Identified)

Technique

• Anesthetize the bleeding site with topical lidocaine before cautery 1, 2
• Restrict cautery application only to the active or suspected bleeding site to minimize mucosal injury 1, 2
• Critical warning: Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 2
• Evidence: Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 2, 3

Fourth-Line Treatment: Nasal Packing

Indications for Nasal Packing

Proceed to nasal packing when: 1, 2

• Bleeding continues after 15-30 minutes of proper compression with vasoconstrictors
• Life-threatening bleeding is present
• Posterior bleeding source is suspected
• Compression, vasoconstrictors, and cautery have all failed

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

Special Populations

Patients on Anticoagulants/Antiplatelets

• Do NOT discontinue anticoagulation or antiplatelet therapy solely for epistaxis management unless bleeding is life-threatening 2
• Initiate first-line local treatments (compression, vasoconstrictors, cautery, packing) before considering withdrawal of these medications 1, 2
• For aspirin specifically: Continue aspirin in high-risk cardiovascular patients, as survival benefits outweigh bleeding risks 2
• It is reasonable for these patients to seek medical evaluation unless bleeding has completely stopped 1

Elderly Patients (≥75 years)

• Triage urgently, as age-related anatomic changes increase likelihood of posterior sources and complications 2
• Higher risk of posterior epistaxis associated with hypertension and atherosclerosis 5

When to Transfer or Refer

Immediate Transfer Indications

• Epistaxis not controlled after 15 minutes of continuous proper compression 1, 2
• Signs of hemodynamic instability (tachycardia, syncope, orthostatic hypotension) 1
• Patient becomes lightheaded from blood loss 1
• Bleeding duration >30 minutes over a 24-hour period 1, 2
• Epistaxis due to trauma with signs of brain injury, obvious nasal deformity, or facial fracture 1

ENT Referral Indications

• Bleeding persists despite appropriate nasal packing 2
• Recurrent epistaxis despite correct local treatment 2, 6
• Need for nasal endoscopy when anterior rhinoscopy fails to identify source 1, 2
• Evaluation for surgical arterial ligation or endovascular embolization (success rates: 97% for endoscopic sphenopalatine artery ligation vs 62% for conventional packing) 2, 3

Prevention and Discharge Instructions

Post-Treatment Care

• Apply petroleum jelly or lubricating agents to nasal mucosa once bleeding stops to prevent recurrence 2
• Recommend regular use of saline nasal sprays to keep mucosa moist 2
• Advise humidifier use, especially in dry environments 2
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7-10 days 2

Documentation Requirements

• Document personal and family history of bleeding disorders 2
• Record outcome of intervention or transition of care 1

Common Pitfalls to Avoid

• Insufficient compression time: Must maintain pressure for full 10-15 minutes without checking 2
• Incorrect head position: Head backward causes blood to enter airway/stomach 1
• Premature anticoagulant discontinuation: Most epistaxis resolves with local measures alone 2
• Bilateral cautery: Significantly increases septal perforation risk 2
• Using non-resorbable packing in anticoagulated patients: Causes trauma during removal 2

Note: Ice packs/cryotherapy have no proven benefit for epistaxis management and should not be relied upon 1, 2