What is the most appropriate treatment for an anterior epistaxis lasting 30 minutes with a visualized bleeding source that is only slowed after 10 minutes of direct pressure?

Treatment of Anterior Epistaxis with Visualized Bleeding Source

For anterior epistaxis with a clearly visualized bleeding site that has only slowed after 10 minutes of pressure, cauterization with silver nitrate is the most appropriate next step, as it is more effective than nasal packing when a bleeding source can be identified. 1

Algorithmic Approach to This Clinical Scenario

Step 1: Anesthetize the Bleeding Site

• Apply topical lidocaine or tetracaine using cotton pledgets soaked with the anesthetic agent directly to the visualized bleeding site 1
• Consider adding a topical vasoconstrictor (oxymetazoline or phenylephrine) to improve visualization and potentially slow bleeding further 1
• Wait 5-10 minutes for adequate anesthesia before proceeding 1

Step 2: Perform Cauterization

• Use silver nitrate (25%-75%) applied directly and exclusively to the visualized bleeding site 1
• Restrict cautery application only to the active bleeding point to minimize tissue injury and prevent septal perforation 1
• Silver nitrate cauterization achieves 80% initial success rates for anterior epistaxis 2
• If available, bipolar electrocautery is superior to chemical cautery (less painful, faster healing), but silver nitrate is acceptable and more readily available in most settings 1

Step 3: Avoid Bilateral Cautery

• Never cauterize both sides of the septum simultaneously, as this significantly increases the risk of septal perforation and necrosis 1

Why Cautery Over Other Options

Evidence Supporting Cautery as First Choice

• Cautery is more effective than nasal packing when a bleeding site can be identified 1
• Cautery is better tolerated by patients compared to packing 1
• No follow-up visit is required for packing removal, improving patient convenience 2

Why NOT the Other Options in This Scenario

Anterior nasal packing with gauze:

• Reserved for situations where bleeding precludes identification of a bleeding site despite compression 1
• Since you have a visualized source, packing is less effective than targeted cautery 1
• Higher recurrence rates (42% for petroleum gauze packing vs. 20% or less for cautery) 2

Hemostatic agents (Surgicel, Avitene, Floseal):

• These resorbable materials are indicated when a bleeding site cannot be clearly visualized or for patients on anticoagulation 1, 3
• With a clearly visible bleeding point, direct cauterization is more definitive 1
• Hemostatic agents like Avitene control only 72-77% of anterior epistaxis initially 4

Nasal balloon:

• Indicated for posterior epistaxis or when anterior measures fail 5
• Higher morbidity and recurrence rates (26% for Merocel) compared to cautery 2
• Requires follow-up for removal and patient education about warning signs 1

Critical Pitfalls to Avoid

• Do not cauterize extensively or "prophylactically" around the bleeding site—this increases complications without improving outcomes 1
• Do not proceed with cautery without adequate anesthesia, as patient movement from pain will compromise effectiveness 1
• Do not use packing as first-line when you can see the bleeding source—this is less effective and increases patient morbidity 1
• Ensure the patient understands this is a 30-minute duration bleed, which qualifies as severe epistaxis requiring definitive treatment, not just observation 1

Special Considerations

If Patient is Anticoagulated

• Still proceed with cautery as first-line treatment 1, 6
• Do not reverse anticoagulation unless there is life-threatening bleeding 1, 7
• If cautery fails and packing is needed, use resorbable materials (Surgicel, Nasopore, Floseal) rather than non-resorbable packing 1

If Cautery Fails

• Apply topical tranexamic acid (TXA) to the bleeding site, which achieves bleeding control in 6.7 minutes on average and reduces recurrence compared to packing 1, 8
• If still bleeding, then proceed to nasal packing with resorbable materials 1