How should I manage an acute epistaxis?

Managing Acute Epistaxis

Lean forward and apply firm, continuous pressure to the soft lower third of your nose for a full 10-15 minutes without checking if bleeding has stopped—this single maneuver resolves the vast majority of nosebleeds. 1, 2

Immediate First-Line Actions

Body Positioning

• Sit upright with your head tilted slightly forward to prevent blood from flowing into your airway or stomach 2, 3
• Breathe through your mouth and spit out blood rather than swallowing it 1, 4

Direct Nasal Compression

• Pinch the soft lower third of the nose (not the bony bridge) with firm, sustained pressure for 10-15 minutes continuously 1, 2
• Do not release pressure intermittently to check if bleeding has stopped—this is the most common cause of treatment failure 2
• Compression alone stops bleeding in the vast majority of anterior nosebleeds 1, 2

If Bleeding Continues After 15 Minutes

Add Topical Vasoconstrictors

• First, blow your nose gently or have clots removed to clear the nasal cavity 1
• Spray oxymetazoline or phenylephrine (2 sprays) into the bleeding nostril 1, 2
• This approach stops bleeding in 65-75% of emergency department cases that don't respond to compression alone 2, 5
• Resume firm compression for another 5-10 minutes after applying the spray 1, 2
• You may repeat this sequence once if needed 1

Important Caution

• Vasoconstrictors carry increased risk of cardiac or systemic complications in patients with undiagnosed hypertension (present in approximately one-third of epistaxis patients) 2
• Avoid repeated or prolonged use, as this can cause rebound congestion (rhinitis medicamentosa) 2

After Bleeding Stops: Prevention

Nasal Moisturization

• Apply petroleum jelly or nasal saline gel to the inside of your nose 2-3 times daily 1, 2, 3
• Use saline nasal sprays frequently throughout the day to keep nasal mucosa moist 1, 2
• Run a humidifier at your bedside, especially in dry environments 1, 2

Activity Restrictions

• Avoid nose blowing, strenuous activity, and heavy lifting for at least 7-10 days 1
• Do not pick your nose or insert tissues/cotton into the nostrils 1

When to Seek Emergency Care

Go to the emergency department or call 911 if: 1, 3

• Bleeding persists after 15-30 minutes of proper continuous compression with vasoconstrictors
• Total bleeding duration exceeds 30 minutes over a 24-hour period
• You feel weak, lightheaded, or dizzy from blood loss
• You have signs of hemodynamic instability (rapid heart rate, low blood pressure)
• Blood is flowing briskly down your throat despite forward positioning

Special Considerations

If You Take Blood Thinners

• Do not stop your anticoagulant or antiplatelet medication (including aspirin) without medical evaluation 1, 2
• These medications are prescribed to prevent serious cardiovascular events—the survival benefits typically outweigh bleeding risks 2
• First-line local measures (compression, vasoconstrictors) should be attempted before considering medication adjustments 2, 4
• If bleeding is severe, hold your next dose but seek immediate medical evaluation 1

If You Take NSAIDs

• Continue your NSAID unless bleeding cannot be controlled with local measures 2
• Standard epistaxis alone is not an indication to discontinue NSAIDs 2

Advanced Treatments (Performed by Medical Professionals)

If home measures fail, your healthcare provider may perform: 1, 2, 5

• Nasal endoscopy to locate the bleeding source (successful in 87-93% of cases)
• Cauterization of the bleeding vessel (electrocautery has 14.5% recurrence vs. 35.1% for chemical cautery)
• Nasal packing with absorbable materials (required when compression, vasoconstrictors, and cautery fail)
• Surgical arterial ligation (97% success rate) or endovascular embolization (80% success rate) for refractory cases

Common Pitfalls to Avoid

• Releasing pressure prematurely before 10-15 minutes have elapsed 2
• Tilting your head backward, which allows blood to flow into your throat 2, 3
• Neglecting nasal moisturization after bleeding stops, leading to recurrent episodes 3, 4
• Stopping prescribed anticoagulants without medical consultation 1, 2