What is the recommended evaluation and management of a patient with epistaxis?

Evaluation and Management of Epistaxis

Immediate First-Line Management

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

Positioning and Initial Steps

• Position the patient seated upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1, 2
• Instruct the patient to breathe through the mouth and expectorate blood rather than swallow it to reduce aspiration risk 1
• Obtain baseline blood pressure measurement immediately because approximately 33% of epistaxis patients have undiagnosed hypertension, and this affects both bleeding risk and vasoconstrictor safety 1

Adjunctive Pharmacologic Therapy

• If compression alone fails after 10–15 minutes, apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 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 presentations, avoiding the need for nasal packing in most cases 1, 3
• Before using vasoconstrictors, verify blood pressure is controlled because these agents carry increased risk of cardiac or systemic complications in hypertensive or cardiovascular-compromised patients 1

Risk Stratification and Documentation

Document the following critical risk factors immediately, as they determine bleeding severity and guide escalation decisions: 1

• Duration of current bleeding episode and total bleeding time over 24 hours (>30 minutes warrants urgent evaluation) 1
• Anticoagulant or antiplatelet medications (warfarin, aspirin, clopidogrel, apixaban, rivaroxaban, dabigatran, NSAIDs) 1, 4
• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia) 1
• Intranasal drug use (recreational inhalants, chronic decongestant overuse) 1
• Prior hospitalization for epistaxis 1
• Bilateral versus unilateral bleeding pattern (bilateral recurrent bleeding suggests hereditary hemorrhagic telangiectasia) 1, 4

Indications for Nasal Packing

Proceed to nasal tamponade only when: 1

• Bleeding persists after 15–30 minutes of proper compression combined with topical vasoconstrictor
• Life-threatening hemorrhage is present
• A posterior bleeding source is suspected

Packing Material Selection

• For patients on anticoagulants or antiplatelet agents, use only resorbable/absorbable materials (Nasopore, Surgicel, Floseal) to minimize trauma during removal 1, 4
• Non-resorbable packing (petroleum jelly gauze, Merocel, Rapid-Rhino) may be used in patients without bleeding risk factors 1

Diagnostic Endoscopy and Cautery

After achieving initial hemostasis, identify the bleeding source to prevent recurrence: 1

• Clean the nasal cavity of clots by suction or gentle nose blowing, then perform anterior rhinoscopy 1, 2
• If anterior rhinoscopy does not identify the source, proceed to nasal endoscopy—this localizes the bleeding site in 87–93% of cases 1, 3
• 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 with fewer recurrences (14.5% vs 35.1%) 1, 3
• Never perform bilateral simultaneous septal cautery because it markedly increases the risk of septal perforation 1

Management of Patients on Antithrombotic Therapy

Do not discontinue anticoagulant or antiplatelet agents before attempting first-line local measures (compression, vasoconstrictor, cautery, packing) unless bleeding is life-threatening. 1

Specific Considerations

• For aspirin in high-risk cardiovascular patients (recent MI, stents), continue aspirin despite epistaxis because survival benefits outweigh bleeding risks 1
• For NSAIDs, standard epistaxis alone is not an indication to stop; most cases resolve with local measures 1
• Anticoagulation reversal is indicated only for life-threatening hemorrhage with hemodynamic instability 1

Reversal Agents (Life-Threatening Hemorrhage Only)

• Warfarin: 4-factor prothrombin complex concentrate (PCC) provides faster INR correction than fresh frozen plasma 1
• Dabigatran: idarucizumab 1
• Other DOACs (apixaban, rivaroxaban, edoxaban): 4-factor PCC 1
• Unfractionated heparin/LMWH: protamine sulfate 1
• Antiplatelet agents: platelet transfusion (effectiveness depends on timing of last dose) 1

Prevention of Recurrence

After hemostasis is achieved, implement these measures to prevent recurrent bleeding: 1

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily 1, 4
• Use saline nasal sprays frequently throughout the day to maintain mucosal moisture 1
• Recommend a humidifier in dry environments 1, 4
• Avoid nose picking, vigorous nose-blowing, and nasal decongestants for 7–10 days after packing removal 1

Red-Flag Signs Requiring Immediate Escalation

Return immediately or transfer to emergency department if: 1

• Active bleeding despite correctly placed tamponade
• Hemodynamic instability (tachycardia, hypotension, dizziness)
• Fever >38.3°C (101°F)
• New visual disturbances
• Bleeding persists >30 minutes total over 24 hours despite proper compression

Criteria for ENT Referral

Refer to otolaryngology when: 1

• Bleeding continues despite appropriate nasal packing
• Recurrent epistaxis occurs despite correct local treatment and preventive measures
• Three or more recent episodes of epistaxis
• Bilateral recurrent nosebleeds (evaluate for hereditary hemorrhagic telangiectasia)
• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes (concern for mass lesion) 2

Advanced Interventions for Refractory Cases

For persistent or recurrent bleeding not controlled by packing or cautery, evaluate candidacy for: 1

• Endoscopic sphenopalatine artery ligation (97% success rate vs 62% for conventional packing) 1, 3
• Endovascular embolization (80% success rate with <10% recurrence vs 50% recurrence for nasal packing) 1, 3

Special Populations

Elderly Patients

• Advanced age dramatically increases epistaxis severity and complications 2
• Elderly patients have significantly higher rates of posterior epistaxis, which is more difficult to control 2
• Posterior epistaxis is more common in elderly patients with hypertension, atherosclerosis, and conditions affecting platelets or clotting 5

Patients with Migraine or Facial Pressure

• Use acetaminophen for pain relief as it does NOT increase bleeding risk 4
• Avoid aspirin and ibuprofen (NSAIDs) as they impair platelet function and increase bleeding 4
• Evaluate for underlying sinus pathology that may be causing both epistaxis and facial symptoms 4

Common Pitfalls to Avoid

• Premature release of compression before the full 10–15 minutes is the most common cause of treatment failure 1
• Checking if bleeding has stopped during compression disrupts clot formation 1
• Using topical vasoconstrictors without first checking blood pressure in potentially hypertensive patients 1
• Discontinuing anticoagulation prematurely before attempting local measures 1
• Bilateral simultaneous septal cautery markedly increases septal perforation risk 1
• Using non-resorbable packing in patients on antithrombotic therapy increases trauma during removal 1
• Delaying endoscopic evaluation after multiple packing failures may miss underlying pathology 1

Follow-Up and Documentation

• Document treatment outcomes within 30 days for patients managed with non-resorbable packing, surgical ligation, or embolization 1
• Educate patients about the type of packing used, expected removal timing, post-procedure care, and warning signs requiring urgent reassessment 1
• Routine follow-up is recommended for patients who have undergone invasive treatments to assess for complications and recurrent bleeding 1