What supportive care should be provided for a patient with frequent epistaxis?

Supportive Care for Frequent Epistaxis

Patients with frequent nosebleeds should implement daily nasal moisturization with saline sprays and petroleum jelly, use a bedside humidifier, avoid digital trauma and vigorous nose blowing, and learn proper compression technique for acute episodes. 1

Prevention and Daily Maintenance

Nasal Moisturization

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2-3 times daily to maintain moisture and reduce recurrence of bleeding. 2
• Use saline nasal sprays frequently throughout the day to keep the nasal mucosa moist, particularly in elderly patients prone to dryness-related bleeding. 2
• Regular moisturization is especially critical because dry, fragile nasal mucosa bleeds more easily. 2

Environmental Modifications

• Use a humidifier at the bedside, particularly in dry environments, since dry heat and abrupt temperature changes create fragile, hyperemic nasal mucosa that bleeds easily. 1, 2

Behavioral Modifications

• Eliminate digital trauma (nose picking) and vigorous nose blowing, as these are major contributing factors to recurrent epistaxis. 1
• Patients should avoid picking or rubbing the nose to allow healing after bleeding episodes. 2

Patient Education on Acute Management

Proper Compression Technique

• Teach patients to 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. 2, 3
• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed. 4, 3
• Instruct the patient to breathe through their mouth and spit out any blood rather than swallowing it. 2, 4, 3

Adjunctive Measures

• After clearing clots by gentle nose blowing, patients can apply 2 sprays of oxymetazoline or phenylephrine nasal spray into the bleeding nostril, then continue compression for another 5-10 minutes. 1, 2, 3
• These topical vasoconstrictors stop bleeding in 65-75% of emergency department cases. 2, 5

When to Seek Medical Attention

Red Flags Requiring Immediate Care

• Bleeding that persists after 15 minutes of continuous proper compression warrants immediate medical evaluation. 2, 3
• Seek care for hemodynamic instability (lightheadedness, dizziness, weakness from blood loss). 2, 3
• Active bleeding despite correctly applied compression, fever >101°F, vision changes, or facial swelling require urgent intervention. 2

Indications for Specialist Referral

• Recurrent bilateral nosebleeds or family history of recurrent nosebleeds should prompt evaluation for hereditary hemorrhagic telangiectasia (HHT). 1, 2, 4
• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes requires urgent ENT consultation to exclude mass lesions. 4
• More than 3 recent episodes of epistaxis warrant evaluation. 2

Special Populations

Patients on Anticoagulants or Antiplatelets

• Do not discontinue anticoagulation for standard epistaxis alone—most cases resolve with local measures, and stopping anticoagulation dramatically increases stroke risk. 4, 3
• Patients on anticoagulants should seek professional medical care for epistaxis unless bleeding has completely stopped. 4, 3
• These patients should use only resorbable packing materials (Nasopore, Surgicel, Floseal) if packing becomes necessary, to minimize trauma during removal. 2, 3

Elderly Patients

• Advanced age dramatically increases epistaxis severity and complications, with significantly higher rates of posterior epistaxis that is more difficult to control. 4
• Elderly patients require more aggressive moisturization strategies and lower thresholds for seeking medical attention. 2, 4

Patients with HHT

• Resorbable packing is strongly preferred for patients with HHT, as removal of nonresorbable packing can irritate the nasal cavity and increase risk of rebleeding. 1
• These patients should be referred to an HHT Center of Excellence for comprehensive management of their complex disease. 1

Common Pitfalls to Avoid

• Insufficient compression time (checking before 10-15 minutes) leads to treatment failure. 3
• Tilting head backward causes blood to flow into the throat and stomach, potentially causing vomiting, and does not help control bleeding. 3
• Repeated or prolonged use of topical vasoconstrictors can precipitate rhinitis medicamentosa and worsening nasal obstruction. 2
• Do not overlook underlying pathology in patients with recurrent unilateral epistaxis—consider nasal masses or malignancy. 2

Follow-Up and Documentation

• Patients who undergo nasal packing, cauterization, or other invasive treatments should have documented outcomes within 30 days to assess for complications and recurrent bleeding. 1, 2
• Adequate follow-up allows assessment for underlying conditions when treatments are ineffective or bleeding recurs. 1