What is the appropriate management for epistaxis?

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Epistaxis Management

Immediate First-Line Intervention

Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking for cessation of bleeding—this single maneuver resolves the vast majority of anterior epistaxis cases and premature release is the most common cause of treatment failure. 1

Proper Positioning and Technique

  • Seat the patient upright with the head tilted slightly forward to prevent blood from entering the airway or stomach. 1
  • Instruct the patient to breathe through the mouth and expectorate blood rather than swallow it. 1
  • The compression must be sustained for the full duration without intermittent checking, as interruption resets the clotting process. 1

Second-Line Pharmacologic Adjunct

If bleeding persists after 10–15 minutes of proper compression:

  • Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril, then resume firm compression for an additional 5–10 minutes. 1
  • This combination stops bleeding in 65–75% of emergency department presentations. 1, 2

Critical Caveat

  • Obtain a baseline blood pressure before using topical vasoconstrictors, because approximately one-third of epistaxis patients have undiagnosed hypertension and vasoconstrictors carry increased risk of cardiac or systemic complications in this subgroup. 1
  • Avoid repeated or prolonged vasoconstrictor use, as this precipitates rhinitis medicamentosa and worsening nasal obstruction. 1

Third-Line Intervention: Cautery

When compression and vasoconstrictors fail and a focal bleeding point is identified:

  • After clot removal by suction or gentle nose blowing, perform anterior rhinoscopy to visualize the bleeding source. 1
  • Anesthetize the identified site with topical lidocaine, then cauterize only the active bleeding point. 1
  • Electrocautery is superior to chemical cauterization (silver nitrate), with recurrence rates of 14.5% versus 35.1%, respectively. 1, 2
  • Never perform bilateral simultaneous septal cautery, as this markedly increases the risk of septal perforation. 1

Fourth-Line Intervention: Nasal Packing

Proceed to nasal packing only when:

  1. Bleeding persists after 15–30 minutes of proper compression combined with vasoconstrictors. 1
  2. Life-threatening hemorrhage is present. 1
  3. A posterior bleeding source is suspected. 1

Packing Material Selection

  • For patients on anticoagulants or antiplatelet agents, use only resorbable/absorbable materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal. 1
  • For patients not on antithrombotic therapy, either resorbable or non-resorbable materials may be used. 1

Post-Packing Care

  • Apply saline nasal spray frequently throughout the day to keep packing moist. 1
  • Educate patients about the type of packing placed, timing and plan for removal, and warning signs requiring immediate reassessment. 1

Management of Anticoagulated Patients

Do not discontinue anticoagulant or antiplatelet agents, nor administer reversal agents or blood products, before attempting first-line local measures (compression, vasoconstrictor, cautery, packing) unless bleeding is life-threatening. 1

Specific Guidance by Agent

  • For aspirin in high-risk cardiovascular patients (recent MI, stents), continue aspirin despite epistaxis—the survival benefits outweigh bleeding risks. 1
  • For NSAIDs, do not routinely discontinue for standard epistaxis; most cases resolve with local measures alone. 1
  • For warfarin with life-threatening hemorrhage, use 4-factor prothrombin complex concentrate (PCC) for faster INR correction with smaller infusion volume compared to fresh frozen plasma. 1
  • For direct oral anticoagulants (DOACs) with life-threatening hemorrhage, use 4-factor PCC; idarucizumab specifically for dabigatran. 1

Advanced Diagnostic Evaluation

When anterior rhinoscopy fails to identify the source or bleeding is difficult to control:

  • Perform nasal endoscopy, which localizes the bleeding site in 87–93% of cases. 1, 2
  • Endoscopy is particularly useful for posterior epistaxis, which can originate from the septum or lateral nasal wall. 1

Escalation to Definitive Intervention

For persistent or recurrent bleeding not controlled by packing or cautery:

  • Evaluate candidacy for surgical arterial ligation (endoscopic sphenopalatine artery ligation) or endovascular embolization. 1
  • Endoscopic sphenopalatine artery ligation has a 97% success rate versus 62% for conventional packing. 1, 2
  • Endovascular embolization has an 80% success rate with recurrence rates <10% compared to 50% for nasal packing. 1, 2

Prevention of Recurrence

Once hemostasis is achieved:

  • Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture. 1
  • Use saline nasal sprays frequently throughout the day. 1
  • Recommend a humidifier in dry environments, as dry heat creates fragile, hyperemic nasal mucosa prone to bleeding. 1, 3
  • Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7–10 days after packing removal. 1

Red-Flag Criteria for Immediate Escalation

Refer to otolaryngology or escalate care immediately if:

  • Active bleeding persists despite correctly placed packing. 1
  • Hemodynamic instability (tachycardia, hypotension, dizziness). 1
  • Fever >38.3°C (101°F). 1
  • New visual disturbances. 1
  • Recurrent bilateral nosebleeds (screen for hereditary hemorrhagic telangiectasia). 1

Documentation Requirements

  • Record duration of bleeding, response to compression, medication history (anticoagulants, antiplatelets, NSAIDs), personal or family history of bleeding disorders, and baseline blood pressure. 1
  • Document outcomes within 30 days for patients treated with non-resorbable packing, surgical ligation, or embolization. 1

Common Pitfalls to Avoid

  • Premature release of compression before the full 10–15 minutes—this is the single most common error leading to treatment failure. 1
  • Discontinuing aspirin in high-risk cardiovascular patients without weighing thrombotic risk. 1
  • Using non-resorbable packing in anticoagulated patients. 1
  • Applying bilateral septal cautery simultaneously. 1
  • Failing to obtain baseline blood pressure before vasoconstrictor use. 1

References

1
Guideline

Epistaxis Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Research

Epistaxis Treatment Options: Literature Review.

Indian journal of otolaryngology and head and neck surgery : official publication of the Association of Otolaryngologists of India, 2023

3
Research

Management of anterior and posterior epistaxis.

American family physician, 1991

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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