How should I manage epistaxis in an elderly patient caused by nasal congestion, including immediate bleeding control and treatment of the underlying irritation?

Management of Epistaxis in Elderly Patients with Nasal Congestion

For elderly patients with nosebleeds caused by nasal congestion, begin with firm sustained compression of the soft lower nose for 10-15 minutes without interruption, followed by topical oxymetazoline or phenylephrine if bleeding persists, then apply nasal saline gel or petroleum jelly after bleeding stops to prevent recurrence. 1, 2

Immediate Bleeding Control

First-Line Intervention: Direct Compression

• Position the patient sitting upright with head tilted slightly forward (not backward) to prevent blood from entering the airway or stomach 1, 2
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped—premature release is a common pitfall that leads to treatment failure 3, 1, 2
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 1
• Compression alone resolves the vast majority of anterior epistaxis cases, which are most common in elderly patients with congestion-related mucosal irritation 1, 4

Second-Line: Topical Vasoconstrictors

• If bleeding continues after 15 minutes of proper compression, clean the nasal cavity of clots by gentle nose blowing or suction 1
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril 1, 5
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 1
• Vasoconstrictors stop bleeding in 65-75% of emergency department cases, making nasal packing unnecessary in most patients 3, 1, 5

Critical caveat: Elderly patients may have undiagnosed hypertension (present in ~33% of epistaxis patients), so obtain baseline blood pressure before using vasoconstrictors, as these agents carry increased risk of cardiac or systemic complications in susceptible patients 3, 1

Treatment of Underlying Congestion and Prevention

Mucosal Moisturization (Primary Prevention Strategy)

• After bleeding stops, apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2-3 times daily 3, 1, 6
• Nasal saline gel as monotherapy achieved 93.2% cessation of recurrent epistaxis at 3 months in anticoagulated elderly patients—a simple, painless alternative to invasive measures 6
• Use saline nasal sprays frequently throughout the day to keep nasal mucosa moist 3, 1, 2
• Recommend humidifier use in dry environments, as dry heat and abrupt temperature changes produce fragile, hyperemic nasal mucosa that bleeds easily 3, 4

What NOT to Do

• Avoid bilateral simultaneous septal cautery—this increases risk of septal perforation 1
• Do not use cauterization in the absence of acute bleeding—it does not address the underlying mucosal dryness and may worsen the condition by extending mucosal disruption, especially problematic in elderly patients 6
• Avoid repeated or prolonged vasoconstrictor use—this leads to rhinitis medicamentosa, loss of efficacy, and worsening nasal obstruction 3

When Initial Measures Fail

Nasal Packing Indications

• Proceed to nasal packing only when: (1) bleeding continues after 15-30 minutes of proper compression with vasoconstrictors, (2) life-threatening bleeding is present, or (3) posterior bleeding source is suspected 3, 1
• Use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) in elderly patients, as most are on anticoagulants or antiplatelet medications—this avoids trauma during removal 1, 2

Identification of Bleeding Site

• After clot removal, perform anterior rhinoscopy to locate the bleeding source 1, 7
• If anterior rhinoscopy fails to identify the source or bleeding is difficult to control, proceed to nasal endoscopy—this localizes the bleeding site in 87-93% of cases 3, 1
• Elderly patients (≥75 years) are at significantly higher risk for posterior epistaxis due to age-related anatomic changes, with those over 85 being 3.24 times more likely to present to emergency departments 2

Special Considerations in the Elderly

Risk Stratification

• Document critical risk factors: personal or family history of bleeding disorders, anticoagulant/antiplatelet use, hypertension, chronic kidney or liver disease, and history of recurrent episodes 1, 2, 7
• Elderly patients with congestion-related epistaxis typically have anterior bleeding from fragile mucosa secondary to sinus disease, allergies, or dry air—less dangerous than posterior bleeds but requiring proper preventive care 4

When to Escalate Care

• Return immediately if bleeding persists after 15 minutes of continuous proper compression, bleeding duration exceeds 30 minutes over 24 hours, or signs of hemodynamic instability develop 1, 7
• Refer to otolaryngology if bleeding continues despite appropriate nasal packing, recurrent epistaxis occurs despite correct local treatment, or bilateral recurrent nosebleeds suggest hereditary hemorrhagic telangiectasia 1, 2, 7

Medication Management

• Do not discontinue anticoagulants or antiplatelet medications (including aspirin) solely for epistaxis treatment unless bleeding is life-threatening—first-line local interventions should be attempted first 1, 2, 7

Post-Treatment Care

• Educate patients to avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7-10 days 1
• Apply moisturizing agents with a cotton-tipped applicator at the first sign of recurrent bleeding 6
• Follow up within 30 days to assess for complications and recurrent bleeding 1, 2