What is the step‑by‑step management of an adult with an anterior nosebleed, including compression, topical vasoconstrictor (oxymetazoline or phenylephrine), cautery, nasal packing, and special considerations for hypertension and anticoagulation (warfarin, direct oral anticoagulants, aspirin)?

Management of Adult Anterior Nosebleed

Begin with firm, continuous compression of the soft lower third of the nose for a full 10–15 minutes without checking for cessation—this single maneuver resolves the vast majority of anterior epistaxis cases. 1

Immediate First-Line Management

Patient Positioning and Compression Technique

• Seat the patient upright with head tilted slightly forward (not backward) 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
• Apply firm, sustained pressure to the soft lower third of the nose—not the nasal bridge—for a full 10–15 minutes without intermittent checking, as premature release is the most common cause of treatment failure 1
• Compression alone stops bleeding in the majority of cases 1

Topical Vasoconstrictor Application

• If bleeding persists after 15 minutes of proper compression, spray oxymetazoline (Afrin) or phenylephrine 2 sprays into the bleeding nostril and resume firm compression for another 5–10 minutes 1
• Vasoconstrictor application stops bleeding in 65–75% of emergency department cases 1, 2
• Obtain baseline blood pressure before using vasoconstrictors because approximately one-third of epistaxis patients have undiagnosed hypertension, and vasoconstrictors carry increased risk of cardiac or systemic complications in this population 1
• Avoid repeated or prolonged vasoconstrictor use, as this precipitates rhinitis medicamentosa and worsening nasal obstruction 1

Advanced Interventions When Compression Fails

Endoscopic Evaluation and Cautery

• After clot removal by suction or gentle nose blowing, perform anterior rhinoscopy to identify the bleeding source 1
• If anterior rhinoscopy is inconclusive or bleeding is difficult to control, proceed to nasal endoscopy, which localizes the bleeding site in 87–93% of cases 1
• When a focal bleeding point is identified, anesthetize with topical lidocaine and cauterize only the active bleeding point 1
• Electrocautery is superior to chemical cauterization (14.5% vs. 35.1% recurrence rate) 2
• Never perform bilateral simultaneous septal cautery—this markedly increases the risk of septal perforation 1

Nasal Packing Indications and Material Selection

• Proceed to nasal packing only when bleeding persists after 15–30 minutes of proper compression combined with vasoconstrictors, life-threatening hemorrhage is present, or a posterior bleeding source is suspected 1

For patients on anticoagulants or antiplatelet medications (warfarin, DOACs, aspirin), use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal. 1, 3

• Non-resorbable packing materials should be avoided in patients on antithrombotic therapy 1
• For patients not on anticoagulants, either resorbable or non-resorbable materials may be used 1

Special Considerations for Hypertension

• Measure blood pressure in all epistaxis patients, as approximately 33% have underlying hypertension that may be undiagnosed 1
• Elevated blood pressure is a marker of cardiovascular risk but is not typically the direct cause of epistaxis 4
• Control hypertension as part of overall management, but do not delay local hemostatic measures 1

Anticoagulation and Antiplatelet Management

General Principle: Local Measures First

Do not discontinue anticoagulants or antiplatelet agents, nor administer reversal agents, before attempting first-line local measures (compression, vasoconstrictor, cautery, packing) unless bleeding is life-threatening. 1, 3

• Local hemostasis is preferred because systemic reversal carries risks associated with plasma, cryoprecipitate, and platelet transfusion exposure 1
• The thrombotic risk from stopping anticoagulation typically outweighs the bleeding risk from minor epistaxis 3

Aspirin-Specific Management

• Continue aspirin for epistaxis management—do not discontinue solely for nosebleed treatment 1
• If the patient is at high cardiovascular risk (recent MI, stents), aspirin must be continued despite epistaxis 1
• Standard local interventions (compression, vasoconstrictors, cautery, packing) should be attempted before considering withdrawal of antiplatelet agents in the absence of massive hemorrhage, hemodynamic instability, or airway compromise 1

Warfarin Management

• Continue warfarin and use local hemostatic measures first for non-life-threatening epistaxis 1, 3
• For life-threatening hemorrhage only: administer fresh frozen plasma, 4-factor prothrombin complex concentrate (PCC), or vitamin K—4-factor PCC provides faster INR correction and requires smaller infusion volume 1

Direct Oral Anticoagulant (DOAC) Management

• Continue DOACs (dabigatran, edoxaban, apixaban, rivaroxaban) and use local measures first 3
• For life-threatening hemorrhage only: administer 4-factor PCC; idarucizumab specifically for dabigatran 1

Prevention of Recurrence

• After hemostasis, apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and reduce recurrence 1, 3
• Use saline nasal sprays frequently throughout the day to keep nasal mucosa moist 1
• Recommend a bedside humidifier in dry environments, as dry heat and abrupt temperature changes create fragile, hyperemic nasal mucosa that bleeds easily 1, 4
• Avoid nose blowing, strenuous activity, heavy lifting, or placing tissues/cotton in the nose for at least 7 days 3

Red-Flag Signs Requiring Immediate Escalation

• Active bleeding despite correctly placed packing 1
• Hemodynamic instability (tachycardia, hypotension) 1
• Bleeding persists after 15–30 minutes of proper compression 1
• Fever > 38.3°C (101°F) 1
• New visual disturbances 1
• Dizziness or other signs of significant blood loss 1

Criteria for ENT Referral

• Persistent bleeding despite appropriate nasal packing 1
• Recurrent epistaxis despite correct local treatment and preventive measures 1
• Bilateral recurrent nosebleeds (evaluate for hereditary hemorrhagic telangiectasia) 1
• Need for assessment of surgical arterial ligation or endovascular embolization—endoscopic sphenopalatine artery ligation has a 97% success rate vs. 62% for conventional packing, with recurrence rates <10% vs. 50% 1, 2

Common Pitfalls to Avoid

• Premature release of compression before the full 10–15 minutes—this is the most common cause of treatment failure 1
• Tilting the head backward instead of forward, which allows blood to enter the airway or stomach 1
• Discontinuing anticoagulants or antiplatelet agents before attempting local measures in non-life-threatening bleeding 1, 3
• Using non-resorbable packing in patients on antithrombotic therapy 1
• Performing bilateral simultaneous septal cautery 1
• Prolonged use of topical vasoconstrictors leading to rhinitis medicamentosa 1

Follow-Up Requirements

• Patients requiring nasal packing, cauterization, or any invasive intervention should have documented follow-up within 30 days to assess for complications and recurrent bleeding 1, 3