For an adult with simple anterior epistaxis and no contraindications (no uncontrolled hypertension, no anticoagulation, no clotting disorder), what are the recommended first‑line treatments and dosages of oxymetazoline and tranexamic acid (topical, oral, and intravenous)?

First-Line Treatment and Dosing for Simple Anterior Epistaxis

For an adult with uncomplicated anterior epistaxis, apply 2 sprays of oxymetazoline (0.05%) into the bleeding nostril after 10–15 minutes of continuous nasal compression, then resume compression for 5–10 minutes; topical tranexamic acid 500 mg (5 mL of injectable formulation) applied directly to the nasal mucosa is superior to oxymetazoline and achieves hemostasis in 71% of cases within 10 minutes. 1

Oxymetazoline Dosing and Application

• Administer 2 sprays of oxymetazoline (0.05% concentration) directly into the bleeding nostril after the initial 10–15 minutes of firm nasal compression. 1
• Resume firm compression for an additional 5–10 minutes after applying the vasoconstrictor to maximize efficacy. 1
• Oxymetazoline stops bleeding in 65–75% of emergency department presentations, making it highly effective as first-line pharmacologic therapy. 1
• Obtain a baseline blood pressure before administering topical vasoconstrictors because approximately one-third of epistaxis patients have undiagnosed hypertension, and vasoconstrictors carry increased risk of cardiac or systemic complications in this population. 1
• Avoid repeated or prolonged use of oxymetazoline because this precipitates rhinitis medicamentosa, loss of efficacy, and worsening nasal obstruction. 1

Tranexamic Acid: Superior Alternative

Topical Tranexamic Acid Dosing

• Apply 1000 mg of topical tranexamic acid (10 mL of the 100 mg/mL injectable formulation) directly to the nasal mucosa for optimal efficacy; this dose is superior to 500 mg and achieves 2.9 times less bleeding at 5 minutes and 4.3 times less rebleeding compared to saline. 2
• The 500 mg dose (5 mL of injectable formulation) arrests bleeding in 71% of patients within 10 minutes, compared to only 31.2% with traditional anterior nasal packing. 3
• Topical tranexamic acid achieves hemostasis in 78% of patients, significantly outperforming oxymetazoline (35% success rate) in head-to-head comparison. 4
• Rebleeding within 24 hours occurs in only 4.7% of patients treated with topical tranexamic acid versus 11% with nasal packing. 3
• 95.3% of patients treated with topical tranexamic acid are discharged within 2 hours, compared to only 6.4% with nasal packing, dramatically improving emergency department throughput. 3

Practical Application Technique

• Use the injectable formulation of tranexamic acid (100 mg/mL) applied topically—this is the most studied and effective preparation. 3
• Apply the solution directly to the bleeding site using gauze or cotton pledgets soaked in the tranexamic acid solution. 3
• Nebulized tranexamic acid is an alternative delivery method for patients who cannot tolerate topical application by other means, though evidence is limited. 5

Oral and Intravenous Tranexamic Acid

• Oral tranexamic acid reduces rebleeding risk from 69% to 49% (RR 0.73,95% CI 0.55–0.96), making it valuable for preventing recurrence after initial hemostasis. 6
• No specific oral or intravenous dosing for epistaxis is established in the guidelines, but the topical route is preferred for anterior epistaxis because it delivers high local concentrations without systemic exposure. 1, 3

Algorithmic Approach to Pharmacologic Management

1. Begin with 10–15 minutes of firm, continuous compression to the soft lower third of the nose without checking for cessation. 1

2. If bleeding persists, choose between two evidence-based options:

   • Oxymetazoline 2 sprays (traditional, widely available, 65–75% success) 1
   • Topical tranexamic acid 1000 mg (superior efficacy, 78% success, lower rebleeding) 2, 4

3. After applying pharmacologic agent, resume compression for 5–10 minutes. 1

4. If hemostasis is achieved, prescribe oral tranexamic acid to reduce rebleeding risk by 27%. 6

5. If bleeding continues after 15–30 minutes of proper compression plus vasoconstrictors, escalate to nasal packing using resorbable materials. 1

Critical Pitfalls to Avoid

• Do not check for bleeding cessation during the initial 10–15 minutes of compression—premature release is a common cause of treatment failure. 1
• Do not use oxymetazoline repeatedly or for prolonged periods because this causes rebound congestion and treatment failure. 1
• Do not skip baseline blood pressure measurement before administering vasoconstrictors in patients who may have undiagnosed hypertension. 1
• Do not use traditional nasal packing as first-line therapy when topical tranexamic acid is available—packing has higher rebleeding rates (11% vs 4.7%), longer hospital stays, and lower patient satisfaction. 3

Post-Treatment Prevention

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily after hemostasis to maintain moisture and reduce recurrence. 1
• Use saline nasal sprays frequently throughout the day to keep the nasal mucosa moist. 1
• Recommend a humidifier in dry environments because dry heat creates fragile, hyperemic nasal mucosa prone to rebleeding. 1