For a patient with epistaxis, how long should observation be continued to confirm hemostasis, especially if they have risk factors such as hypertension, anticoagulant therapy, bleeding diathesis, recent nasal trauma, or recurrent nosebleeds?

Observation Period After Epistaxis Control

After achieving initial hemostasis with compression and/or topical vasoconstrictors, observe the patient for a minimum of 10–15 minutes without disturbing the nose to confirm that bleeding has truly stopped. 1

Standard Observation Protocol

• Apply firm, continuous pressure to the soft lower third of the nose for 10–15 minutes without intermittently checking for cessation of bleeding—premature release is the most common cause of treatment failure. 1

• After the initial 10–15 minute compression period, maintain observation for an additional 10–15 minutes to ensure hemostasis is sustained before discharge. 1, 2

• Bleeding that persists beyond 15 minutes of continuous manual pressure requires medical evaluation and escalation to topical vasoconstrictors, cautery, or nasal packing. 2

Extended Observation for High-Risk Patients

For patients with the risk factors you describe—hypertension, anticoagulant therapy, bleeding diathesis, recent nasal trauma, or recurrent nosebleeds—a longer observation period of 30 minutes to several hours is warranted before confirming true hemostasis. 1

Specific High-Risk Considerations:

• Patients on anticoagulant or antiplatelet medications should not be discharged unless bleeding has completely stopped, as they are at higher risk for recurrent bleeding even after apparent initial control. 2

• Elderly patients (≥75 years) with hypertension are at high risk for posterior sources and require endoscopic evaluation if bleeding recurs, necessitating extended observation. 3

• Patients with recent nasal trauma and septal fracture require hemodynamic stability assessment and extended monitoring for delayed re-bleeding. 1

• Bleeding duration greater than 30 minutes over a 24-hour period is considered severe epistaxis and warrants prompt medical evaluation rather than outpatient observation. 1, 2

Red-Flag Signs Requiring Immediate Re-Intervention

Do not discharge if any of the following occur during observation: 1

• Active bleeding despite correctly placed tamponade
• Hemodynamic instability (tachycardia, hypotension, orthostatic changes)
• Lightheadedness or signs of significant blood loss
• Fever >38.3°C (101°F)
• New visual disturbances

Post-Observation Discharge Criteria

Before discharge, confirm all of the following: 1

• No active bleeding for at least 10–15 minutes after final intervention
• Hemodynamically stable vital signs
• Patient able to demonstrate proper compression technique
• Clear instructions provided on warning signs requiring immediate return

Follow-Up Timing

• Routine follow-up within 30 days is recommended for patients who have undergone invasive treatments (packing, cautery) to assess for complications and recurrent bleeding. 1

• More than 3 recent episodes of nasal bleeding may indicate the need for specialist evaluation even if the current episode is controlled. 2

Common Pitfalls to Avoid

• Do not check for bleeding cessation during the initial 10–15 minute compression period—this disrupts clot formation and is the leading cause of failed conservative management. 1

• Do not discharge patients on anticoagulation after brief observation—they require extended monitoring and clear return precautions. 2

• Do not assume anterior epistaxis in elderly hypertensive patients—they have significantly higher rates of posterior sources requiring endoscopic evaluation. 3