In an elderly resident of a skilled nursing facility who recently underwent a rhinoscopy and now has a nosebleed lasting 30 minutes, what should be done?

Management of 30-Minute Nosebleed in Skilled Nursing Facility Resident

Apply firm, continuous compression to the soft lower third of the nose for a full 10–15 minutes without releasing to check if bleeding has stopped, and if bleeding persists after this compression, transfer immediately to the emergency department because 30 minutes of bleeding meets the threshold for severe epistaxis requiring prompt medical evaluation. 1

Immediate Actions at the Skilled Nursing Facility

First-Line Compression Technique

• Position the resident sitting upright with head tilted slightly forward to prevent blood from entering the airway or being swallowed. 1
• Apply firm, sustained 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, 2
• Instruct the resident to breathe through the mouth and spit out blood rather than swallow it to reduce aspiration risk and allow assessment of ongoing blood loss. 1

If Bleeding Continues After 15 Minutes of Proper Compression

• Clear the nasal cavity of blood clots by gentle suction or having the resident blow their nose once, then immediately apply a topical vasoconstrictor. 1
• Spray oxymetazoline (Afrin) or phenylephrine 2 sprays into the bleeding nostril, which stops bleeding in 65–75% of emergency department cases. 1, 3
• Resume firm compression for another 5–10 minutes after applying the vasoconstrictor. 1

Critical Assessment During Compression

Signs Requiring Immediate Emergency Transfer

• Check for tachycardia, hypotension, pallor, lightheadedness, or weakness—any of these indicate significant blood loss requiring hospital-level care. 1
• Bleeding duration exceeding 30 minutes within a 24-hour period is classified as severe epistaxis and warrants prompt emergency department evaluation. 1
• Active bleeding despite correctly placed compression after 15–30 minutes is an indication for nasal packing, which cannot be safely performed in most skilled nursing facilities. 1

Document Critical Risk Factors

• Record anticoagulant or antiplatelet medication use (warfarin, aspirin, clopidogrel, apixaban, rivaroxaban, dabigatran)—these dramatically increase bleeding severity. 2, 1
• Note the recent rhinoscopy procedure as a potential cause of mucosal trauma or disruption of healing tissue. 4
• Document personal or family history of bleeding disorders (von Willebrand disease, hemophilia) to guide emergency department management. 2, 1

Why Transfer to Emergency Department is Necessary

This Resident Requires Advanced Intervention

• The 30-minute bleeding duration combined with prior rhinoscopy and need for previous "rhino rocket" (nasal packing) indicates recurrent, difficult-to-control epistaxis requiring specialist evaluation. 1
• Elderly residents have significantly higher rates of posterior epistaxis, which originates from deeper vessels and cannot be controlled with simple compression alone. 4
• Nasal endoscopy is required to identify the bleeding source after multiple packing attempts or prolonged bleeding, localizing the site in 87–93% of cases. 1

Advanced Treatments Available Only in Hospital Setting

• Resorbable nasal packing materials (Nasopore, Surgicel, Floseal) must be used if the resident is on anticoagulants or antiplatelets to minimize trauma during removal. 1, 5
• If packing fails, evaluation for surgical arterial ligation or endovascular embolization is necessary—these have recurrence rates less than 10% compared to 50% for nasal packing alone. 1, 3
• Endoscopic sphenopalatine artery ligation has a 97% success rate versus 62% for conventional packing in refractory cases. 1, 3

Common Pitfalls to Avoid

• Do not release compression prematurely to check if bleeding has stopped—this is the most frequent cause of treatment failure. 1
• Do not attempt to lower blood pressure acutely during active epistaxis—excessive reduction can cause renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension. 4
• Do not discontinue anticoagulants or antiplatelets before attempting local hemostatic measures unless bleeding is life-threatening. 1, 5
• Do not delay emergency transfer if bleeding persists beyond 15–30 minutes of proper compression with vasoconstrictors—this resident has already exceeded safe observation time. 1

What to Communicate to Emergency Department

• Total bleeding duration (30+ minutes), response to compression attempts, and any vasoconstrictors already applied. 1
• Complete medication list, especially anticoagulants, antiplatelets, NSAIDs, and intranasal medications. 2, 1
• History of recent rhinoscopy and prior nasal packing ("rhino rocket"), indicating recurrent epistaxis. 1
• Vital signs including blood pressure—approximately 33% of epistaxis patients have undiagnosed hypertension. 1