From the Guidelines
The initial evaluation and management of epistaxis should prioritize direct pressure by pinching the soft part of the nose for 10-15 minutes while the patient sits upright and leans slightly forward, as this is the most effective first-line treatment, according to the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The approach to epistaxis evaluation involves several key steps, including:
- Assessing the severity of the bleeding and identifying the bleeding site
- Applying direct pressure to control the bleeding
- Using topical vasoconstrictors, such as oxymetazoline or phenylephrine spray, to reduce bleeding
- Considering chemical cautery with silver nitrate after local anesthesia with lidocaine for persistent bleeding
- Using anterior nasal packing with materials like Merocel or petroleum gauze for 24-72 hours, with prophylactic antibiotics to prevent toxic shock syndrome and sinusitis, if bleeding continues The most recent and highest quality study, published in 2024, emphasizes the importance of nasal pressure alone as the only intervention required in the vast majority of cases, including 20% of cases managed in emergency departments 1. Key considerations in the evaluation and management of epistaxis include:
- Checking vital signs and hemoglobin levels in severe cases
- Investigating underlying causes, such as hypertension, anticoagulant use, coagulopathies, or nasal tumors
- Recommending nasal saline sprays and petroleum jelly to the anterior nares to prevent recurrence by maintaining mucosal moisture after acute management. It is essential to note that the treatment of epistaxis involves a step-wise approach, with the initial step being direct pressure, and subsequent steps being taken as needed to control the bleeding, as outlined in the clinical practice guideline: nosebleed (epistaxis) executive summary 1.
From the Research
Epistaxis Evaluation
- Epistaxis is a common emergency encountered by primary care physicians, with up to 60% of the general population experiencing it, and 6% seeking medical attention for it 2.
- Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency 2.
- The initial assessment of epistaxis patients commonly includes first aid measures, observations, focused history taking, and clinical examinations and investigations 3.
Risk Factors and Management
- Risk factors for epistaxis include local trauma, foreign body insertion, substance abuse, neoplasms, inherited bleeding diatheses, or acquired coagulopathies 4.
- Management options for epistaxis include topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention 4.
- Compressive therapy is the first step to controlling anterior epistaxis, and oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 may be useful adjuncts to compressive therapy 2.
Treatment Outcomes
- The use of oxymetazoline as a sole therapy can effectively treat epistaxis in 65% of patients, and an additional 18% can be managed successfully with silver nitrate cautery in combination with oxymetazoline 5.
- Topical intranasal tranexamic acid does not reduce the need for anterior nasal packing in adult patients presenting to the ED with persistent epistaxis 6.
- Posterior epistaxis is more likely to require hospitalization and twice as likely to need nasal packing, which is often associated with pain and a risk of aspiration if it is dislodged 2.