In an otherwise healthy adult or adolescent with an acute nosebleed, how many sprays of a topical vasoconstrictor (e.g., oxymetazoline or phenylephrine) may be given?

Oxymetazoline Nasal Spray Dosing for Acute Epistaxis

For an acute nosebleed in an otherwise healthy adult or adolescent, apply 2 sprays of oxymetazoline 0.05% directly into the bleeding nostril, followed immediately by firm compression of the soft lower third of the nose for 5–10 minutes without interruption. 1

Initial Treatment Protocol

• First, have the patient blow their nose to clear clots and allow the medication to reach the bleeding site 1
• Apply 2 sprays of oxymetazoline 0.05% (e.g., Afrin) directly to the bleeding nostril 1, 2
• Immediately compress the soft lower third of the nose firmly for a full 5–10 minutes without checking for cessation 1, 2
• Have the patient lean forward during compression to prevent blood from flowing down the throat 1
• This approach achieves hemostasis in approximately 65–75% of cases 1, 3

If Bleeding Persists

• If bleeding continues after the initial 5 minutes, repeat the spray-and-compression sequence once 1
• An additional 18% of patients achieve hemostasis with silver nitrate cautery combined with oxymetazoline 3
• If bleeding persists after two attempts of oxymetazoline plus compression, or if the patient experiences weakness, light-headedness, or severe bleeding, seek emergency care immediately 1

Critical Safety Warnings

• Limit use to ≤3–5 consecutive days maximum to avoid rhinitis medicamentosa (rebound congestion) and mucosal damage that can provoke further epistaxis 1, 2, 4
• Avoid in patients with uncontrolled hypertension because systemic vasoconstriction may precipitate cardiovascular complications 1, 2
• Use with caution in patients with cardiovascular disease or glaucoma due to potential systemic vasoconstrictive effects 1, 2

Post-Hemostasis Care

• After bleeding stops, immediately switch to nasal saline spray or gel applied 2–4 times daily 1, 2
• This moisturization strategy reduces recurrent epistaxis in up to 65% of cases 1, 2
• Continue saline moisturization even after bleeding resolves to prevent recurrence 2

Common Pitfalls to Avoid

• Do not check for cessation before 5 minutes—premature release of compression is a leading cause of treatment failure 1
• Do not tilt the head backward—this directs blood toward the throat and does not aid hemostasis 1
• Do not use oxymetazoline prophylactically—it is intended only for active bleeding, followed by saline moisturization 1
• Do not walk away after spraying—maintain continuous compression for the full 5–10 minutes 1

Alternative Vasoconstrictors

• Phenylephrine nasal spray provides comparable efficacy to oxymetazoline and may be used when oxymetazoline is unavailable 1, 2
• The FDA-approved dosing for oxymetazoline in adults and children ≥6 years is 2–3 sprays per nostril every 10–12 hours, not exceeding 2 doses in 24 hours 5

Emerging Evidence

• Topical tranexamic acid (TXA) achieves hemostasis in approximately 78% of patients, markedly higher than the 35% success rate with oxymetazoline alone 1, 6, 7
• However, the American Academy of Otolaryngology–Head and Neck Surgery notes that TXA data are of moderate quality and require additional high-quality research before adoption as first-line therapy 1