How should I manage an anterior epistaxis in a patient with severe hypertension?

Management of Anterior Epistaxis in Severe Hypertension

In a patient with anterior epistaxis and severe hypertension, focus exclusively on achieving local hemostasis through compression, topical vasoconstrictors, and nasal packing if needed—do not attempt to acutely lower blood pressure during the bleeding episode, as the elevated pressure is typically a stress response rather than the cause of bleeding. 1

Why Blood Pressure Control Is Not the Priority

• Elevated blood pressure during epistaxis is predominantly a stress response to the bleeding event itself, not the underlying cause; attempting acute BP reduction does not improve bleeding control and may delay definitive local hemostasis. 2, 3
• The 2020 American Academy of Otolaryngology-Head and Neck Surgery guideline provides limited guidance on hypertension management during epistaxis because the literature lacks adequate methodologic quality and multivariate analyses to establish a true causative relationship. 2
• Approximately 33% of epistaxis patients have undiagnosed hypertension, so obtaining a baseline blood pressure measurement is important for future cardiovascular risk stratification—but this is a secondary concern after bleeding control. 1

Immediate Local Hemostasis Protocol

First-Line Compression (10–15 minutes)

• Position the patient seated upright with head tilted slightly forward to prevent blood from entering the airway or stomach. 1
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without intermittent checking; premature release is the most common cause of treatment failure. 1
• Instruct the patient to breathe through the mouth and expectorate blood rather than swallow it. 1
• Compression alone resolves the vast majority of anterior epistaxis cases, making it the cornerstone of initial management regardless of blood pressure. 1

Topical Vasoconstrictor Application

• If compression alone fails after 10–15 minutes, apply oxymetazoline or phenylephrine spray (2 sprays into the bleeding nostril) and resume firm compression for another 5–10 minutes. 1
• Topical vasoconstrictors stop bleeding in 65–75% of emergency department cases, thereby avoiding nasal packing in most patients. 1
• Before using topical vasoconstrictors, document the baseline blood pressure because these agents carry increased risk of cardiac or systemic complications in patients with undiagnosed or poorly controlled hypertension. 1

Nasal Packing (if compression + vasoconstrictor fail)

• Proceed to nasal packing only when bleeding persists after 15–30 minutes of proper compression combined with topical vasoconstrictor, when life-threatening hemorrhage is present, or when a posterior source is suspected. 1
• In patients on anticoagulants or antiplatelet agents, use only absorbable packing materials (Nasopore, Surgicel, Floseal) to minimize trauma during removal. 1
• Non-absorbable packing may be used in patients without bleeding risk factors. 1

Common Pitfalls to Avoid

• Do not delay local hemostatic measures while attempting to lower blood pressure; the elevated BP will typically normalize once bleeding is controlled and the patient's anxiety resolves. 2, 3
• Do not withhold topical vasoconstrictors solely because of hypertension; the benefit of local hemostasis outweighs the small systemic absorption risk, but document the baseline BP first. 1
• Do not check for cessation of bleeding before the full 10–15 minutes of compression; premature release restarts the bleeding cascade. 1

Post-Hemostasis Prevention

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and reduce recurrence. 1
• Recommend regular saline nasal sprays throughout the day and humidifier use in dry environments. 1
• Arrange outpatient follow-up for blood pressure management after the acute episode, as hypertension is a significant risk factor for recurrent and more severe epistaxis. 4

Indications for Escalation

• Active bleeding despite correctly placed nasal packing warrants immediate otolaryngology referral. 1
• Hemodynamic instability, fever >101°F, visual changes, or signs of significant blood loss require urgent specialist evaluation. 1
• Recurrent epistaxis despite appropriate local treatment and preventive measures should prompt ENT referral for endoscopic evaluation and consideration of arterial ligation or embolization. 1