How should I treat an uncomplicated nosebleed in an adult, and what additional measures are required for patients on anticoagulants or with hypertension?

Management of Uncomplicated Nosebleed in Adults

Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking if bleeding has stopped—this single maneuver resolves the vast majority of anterior epistaxis cases. 1

Immediate First-Line Treatment

Patient Positioning and Compression

• Seat the patient upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1
• Instruct the patient to breathe through the mouth and spit out blood rather than swallow it 1
• Apply firm, sustained compression to the soft lower third of the nose for a minimum of 10–15 minutes without intermittent release—premature checking is the most common cause of treatment failure 1
• Compression alone resolves the majority of anterior epistaxis, accounting for roughly 20% of emergency department presentations 1

If Bleeding Persists After 10–15 Minutes

• Clear the nasal cavity of blood clots by suction or gentle nose blowing 1
• Apply topical vasoconstrictor spray (oxymetazoline 0.05% or phenylephrine) 2 sprays into the bleeding nostril 1, 2
• Resume firm compression for an additional 5–10 minutes after applying the vasoconstrictor 1
• Vasoconstrictor application stops bleeding in 65–75% of emergency department cases 1, 3

Definitive Treatment When Bleeding Site Is Identified

• Perform anterior rhinoscopy after clot removal to identify the bleeding source 1, 4
• If a focal bleeding point is found, anesthetize the site with topical lidocaine or tetracaine 1
• Apply cautery strictly to the active bleeding point only—avoid bilateral simultaneous septal cautery because it markedly increases the risk of septal perforation 1
• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 1, 3

Post-Treatment Prevention

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and reduce recurrence 1, 2
• Use saline nasal sprays frequently throughout the day to keep the nasal mucosa moist 1, 2
• Recommend a humidifier in dry environments, since dry heat creates fragile, hyperemic nasal mucosa that bleeds easily 1, 5
• Avoid nose blowing, strenuous activity, heavy lifting, or placing cotton or tissues in the nose for at least 7 days 6

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Additional Measures for Patients on Anticoagulants

Critical Principle: Do Not Stop Anticoagulation for Uncomplicated Epistaxis

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

• Patients with epistaxis who are hemodynamically stable, without significant blood loss, and have controlled bleeding with local measures do not require reversal of anticoagulation 1
• For aspirin specifically, if the patient is at high risk of cardiovascular events (recent MI or stents), aspirin should be continued despite epistaxis 1
• Local hemostasis is preferred because systemic reversal carries risks associated with plasma, cryoprecipitate, and platelet transfusion exposure 1

Modified Packing Strategy

• If nasal packing becomes necessary, use only resorbable/absorbable materials (Nasopore, Surgicel, or Floseal) in patients on anticoagulants or antiplatelet medications to minimize trauma during removal 1, 4
• Non-resorbable packing devices should be avoided in individuals on antiplatelet medications 1

When to Consider Reversal (Life-Threatening Bleeding Only)

• Reversal is indicated only for massive hemorrhage, hemodynamic instability, or airway compromise 1
• Warfarin: 4-factor prothrombin complex concentrate (PCC) provides faster INR correction and requires smaller infusion volume than fresh frozen plasma 1
• Direct oral anticoagulants (apixaban, rivaroxaban, dabigatran, edoxaban): Administer 4-factor PCC; idarucizumab specifically for dabigatran 1
• Apixaban specifically: For life-threatening bleeding, give andexanet alfa 400 mg IV bolus over 15 minutes followed by 480 mg infusion over 2 hours (low-dose scenario), or 800 mg bolus over 30 minutes followed by 960 mg infusion over 2 hours (high-dose scenario); if unavailable, give 2,000 units of 4-factor PCC 1
• Platelet inhibitors (aspirin, clopidogrel, prasugrel, ticagrelor): Platelet transfusion (effectiveness depends on timing of last dose) 1

NSAIDs Specifically

• Patients taking NSAIDs who develop epistaxis should be managed with the same standard protocol without discontinuing the NSAID unless bleeding cannot be controlled with local measures 1
• NSAIDs produce significant platelet dysfunction through antiplatelet effects, which should be considered in the multifactorial etiology 1
• For other NSAIDs (not aspirin), if discontinuation is necessary perioperatively or for severe bleeding, withhold for five elimination half-lives 1

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Additional Measures for Patients with Hypertension

Blood Pressure Management During Active Epistaxis

Routine acute blood pressure lowering is NOT recommended during active epistaxis—excessive reduction can cause or worsen renal, cerebral, or coronary ischemia. 4

• Obtain a baseline blood pressure measurement because approximately 33% of patients with epistaxis have underlying undiagnosed hypertension 1
• Blood pressure should be monitored, with decisions about control based on bleeding severity, inability to control bleeding, individual comorbidities, and risks of blood pressure reduction 4
• Do not aggressively lower blood pressure acutely, as this can cause end-organ ischemia in elderly patients with chronic hypertension 4

Vasoconstrictor Precautions

• Before using topical vasoconstrictors (oxymetazoline or phenylephrine), obtain a baseline blood pressure because vasoconstrictors carry an increased risk of cardiac or systemic complications in hypertensive patients 1, 2
• Avoid repeated or prolonged use of topical vasoconstrictors, as this can precipitate rhinitis medicamentosa, loss of efficacy, and worsening nasal obstruction 1

Higher Risk Profile

• Hypertension is independently associated with more severe bleeding requiring emergency intervention 4
• Elderly patients with hypertension are at high risk for posterior sources requiring endoscopic evaluation 4

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When to Escalate Care

Indications for Nasal Packing

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

Red-Flag Signs Requiring Immediate Emergency Department Evaluation

• Active bleeding despite correctly placed packing 1
• Hemodynamic instability (tachycardia, hypotension) 1, 4
• Bleeding duration exceeds 30 minutes over a 24-hour period 1
• Fever > 38.3°C (101°F) 1
• New visual disturbances 1
• Dizziness, lightheadedness, or other signs of significant blood loss 1

Indications 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
• Evaluation for surgical arterial ligation or endovascular embolization when persistent bleeding necessitates advanced intervention 1
• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 1
• Endovascular embolization has an 80% success rate with recurrence rates less than 10% compared to 50% for nasal packing 1

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Common Pitfalls to Avoid

• Premature release of compression: Checking if bleeding has stopped before 10–15 minutes is the most common cause of treatment failure 1
• Stopping anticoagulation prematurely: Most epistaxis resolves with local measures alone; do not discontinue anticoagulants unless bleeding is life-threatening 1
• Aggressive acute blood pressure lowering: Can cause end-organ ischemia in elderly hypertensive patients 4
• Bilateral simultaneous septal cautery: Markedly increases the risk of septal perforation 1
• Using non-resorbable packing in anticoagulated patients: Increases trauma during removal 1
• Prolonged vasoconstrictor use: Do not use oxymetazoline or phenylephrine continuously for more than 3–5 days due to risk of rhinitis medicamentosa 2