How should I manage an acute epistaxis, including initial pressure, topical vasoconstrictor use, cautery, nasal packing, and criteria for emergency referral, particularly in patients on anticoagulant or antiplatelet therapy?

Management of Acute Epistaxis

Begin with firm, sustained compression of the soft lower third of the nose for 10–15 minutes without interruption—this single maneuver resolves the vast majority of anterior nosebleeds and is the foundation of all epistaxis management. 1

Initial Assessment and Triage

Assess severity immediately by evaluating:

• Hemodynamic stability (blood pressure, heart rate, orthostatic changes) 1
• Bleeding duration >30 minutes over 24 hours indicates severe epistaxis 1
• Signs of hypovolemia (tachycardia, syncope, hypotension) warrant emergency management 1
• Bilateral bleeding or blood in the posterior pharynx suggests posterior source 1

Document critical risk factors that increase bleeding severity 1:

• All anticoagulant/antiplatelet medications (warfarin, DOACs, aspirin, clopidogrel, NSAIDs) 1
• Personal or family history of bleeding disorders 1
• Intranasal drug use 1
• Prior nasal surgery, trauma, or oxygen cannula use 1

Step-by-Step Treatment Algorithm

Step 1: Compression (First-Line for ALL Patients)

Position the patient seated with head tilted slightly forward to prevent blood entering the airway or stomach 2. Have them breathe through their mouth and expectorate blood rather than swallow it 1, 2.

Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking if bleeding has stopped—premature release is the most common cause of treatment failure 1, 2. This can be performed by the patient, caregiver, or clinician 1.

Step 2: Topical Vasoconstrictors (If Compression Alone Fails)

Apply oxymetazoline or phenylephrine spray (2 sprays into the bleeding nostril) after the initial compression period 1, 2. This stops bleeding in 65–75% of emergency department cases 1, 2.

Resume firm compression for an additional 5–10 minutes after vasoconstrictor application 2.

Obtain baseline blood pressure before using vasoconstrictors because approximately one-third of epistaxis patients have undiagnosed hypertension, and vasoconstrictors carry increased cardiac risk in this population 2. However, do not routinely lower blood pressure during acute epistaxis, as excessive reduction may cause renal, cerebral, or coronary ischemia 1.

Step 3: Identify the Bleeding Site

After achieving temporary control, perform anterior rhinoscopy after removing any blood clots by suction or gentle nose blowing 1, 2.

If the source remains unclear or bleeding is difficult to control, proceed to nasal endoscopy—this localizes the bleeding site in 87–93% of cases 2, 3.

Step 4: Cautery (When a Focal Site is Identified)

Anesthetize the bleeding site with topical lidocaine or tetracaine before cauterization 1, 2, 4.

Restrict cautery application strictly to the active bleeding point(s) 1, 2. Electrocautery is more effective than chemical cauterization, with recurrence rates of 14.5% versus 35.1% 2, 3.

Never perform bilateral simultaneous septal cautery—this markedly increases the risk of septal perforation 1, 2.

Step 5: Nasal Packing (When Other Measures Fail)

Indications for nasal packing 1, 2:

• Bleeding persists after 15–30 minutes of proper compression with vasoconstrictors
• Life-threatening hemorrhage
• Suspected posterior bleeding source

Critical Management for Patients on Anticoagulants/Antiplatelets

Use ONLY resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) in patients taking anticoagulants or antiplatelet medications to minimize trauma during removal 1, 2. This is a strong recommendation that is frequently underutilized 1.

Do NOT discontinue anticoagulants, reverse anticoagulation, or administer blood products before attempting first-line local measures (compression, vasoconstrictors, cautery, packing) unless bleeding is life-threatening 1, 2. Local hemostasis is preferred because systemic reversal carries significant risks 2.

For low-dose aspirin alone (without other anticoagulants), standard non-resorbable packing may be used 1.

Post-Treatment Prevention

Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily after hemostasis to prevent recurrence 2.

Use saline nasal sprays frequently throughout the day to maintain mucosal moisture 1, 2.

Recommend humidifier use in dry environments 2.

Instruct patients to avoid aspirin and ibuprofen (acetaminophen is safe), avoid nose blowing if packing is in place, and sneeze with mouth open 1.

Criteria for Emergency Referral or ENT Consultation

Immediate referral is required for 1, 2:

• Hemodynamic instability despite initial management
• Airway compromise from blood in the oropharynx
• Active bleeding despite appropriate nasal packing
• Fever >101°F with packing in place
• Vision changes or facial swelling
• Suspected posterior epistaxis requiring posterior packing

Urgent ENT referral within 24–48 hours for 1, 2:

• Bleeding persists despite proper compression, vasoconstrictors, and cautery
• Recurrent epistaxis despite appropriate treatment
• Three or more recent episodes of nasal bleeding
• Bilateral recurrent nosebleeds (evaluate for hereditary hemorrhagic telangiectasia) 1, 2
• Unilateral recurrent bleeding (exclude masses or malignancy) 2

Consider evaluation for surgical arterial ligation or endovascular embolization when persistent bleeding is not controlled by packing or cautery—these have success rates of 97% and 80% respectively, with recurrence rates <10% compared to 50% for nasal packing 2, 3.

Common Pitfalls to Avoid

• Insufficient compression time: Must maintain full 10–15 minutes without checking 1, 2
• Using non-resorbable packing in anticoagulated patients: Always use resorbable materials 1, 2
• Premature discontinuation of anticoagulation: Attempt local measures first 1, 2
• Bilateral septal cautery: Markedly increases perforation risk 1, 2
• Neglecting mucosal moisturization: Leads to recurrent episodes 2
• Overlooking hereditary hemorrhagic telangiectasia: Screen patients with bilateral recurrent bleeds 1, 2

Post-Packing Instructions

Educate patients about 1:

• Type of packing placed and whether it is resorbable
• Timing and plan for removal (if non-resorbable)
• Warning signs requiring immediate reassessment: return of bleeding, fever >101°F, vision changes, shortness of breath, facial swelling 1
• Keep packing moist with frequent saline spray application 2

Document treatment outcomes within 30 days for quality assurance and to assess for underlying pathology 1, 2.