How do I manage an adult with epistaxis, including first‑line pressure, topical vasoconstrictors, cautery, packing, and criteria for ENT referral?

Management of Adult Epistaxis

First-Line Intervention: Nasal Compression

Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking for cessation of bleeding; premature release is the most common cause of treatment failure. 1

• Position the patient seated upright with the head tilted slightly forward to prevent blood from entering the airway or stomach. 1
• Instruct the patient to breathe through the mouth and expectorate blood rather than swallow it. 1
• Compression alone resolves the vast majority of anterior epistaxis cases. 1
• While applying compression, obtain a baseline blood pressure measurement because approximately one-third of epistaxis patients have undiagnosed hypertension. 1
• During compression, document critical risk factors: duration of bleeding, use of anticoagulants/antiplatelets (warfarin, aspirin, clopidogrel, direct oral anticoagulants, NSAIDs), personal or family history of bleeding disorders (von Willebrand disease, hemophilia), intranasal drug use, and prior nasal surgery. 2, 1

Topical Vasoconstrictors

If bleeding persists after 10–15 minutes of proper compression, apply two sprays of oxymetazoline or phenylephrine into the bleeding nostril and resume firm compression for an additional 5–10 minutes. 1

• Topical vasoconstrictors achieve hemostasis in 65–75% of emergency department epistaxis cases. 1, 3
• Before using vasoconstrictors, verify blood pressure is documented because these agents carry increased cardiac or systemic complications in hypertensive patients. 1
• Avoid repeated or prolonged vasoconstrictor use, as this can precipitate rhinitis medicamentosa and worsening nasal obstruction. 1

Identification of Bleeding Source

After clot removal by suction or gentle nose blowing, perform anterior rhinoscopy to identify the bleeding site. 1

• If anterior rhinoscopy fails to identify the source or bleeding is difficult to control, proceed immediately to nasal endoscopy of the nasal cavity and nasopharynx, which localizes the bleeding site in 87–93% of cases. 1, 4
• Ongoing bleeding that tracks into the posterior pharynx during compression indicates a posterior source and warrants escalation beyond simple compression. 4

Cautery (When Focal Bleeding Point Identified)

Anesthetize the identified bleeding site with topical lidocaine or tetracaine, then cauterize only the active bleeding point using bipolar electrocautery or chemical cautery. 1, 4

• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%). 1, 3
• Avoid bilateral simultaneous septal cautery because it markedly increases the risk of septal perforation. 1, 4
• Endoscopic cauterization eliminates the need for nasal packing in approximately 74% of posterior epistaxis cases. 4

Nasal Packing (Reserved Indications)

Proceed to nasal packing only when: (1) bleeding persists after 15–30 minutes of proper compression combined with vasoconstrictors, (2) life-threatening hemorrhage is present, (3) failed endoscopic visualization and cautery, or (4) a posterior bleeding source is suspected. 2, 1, 4

Selection of Packing Material

• For patients on anticoagulants or antiplatelet medications, use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to minimize trauma during removal. 2, 1, 4
• For patients without bleeding risk factors, either resorbable or non-resorbable packing may be used. 1, 4
• After packing placement, educate patients about the type of packing used, timing and plan for removal (or expected resorption), and warning signs requiring immediate reassessment. 1
• Instruct patients to apply saline nasal spray frequently throughout the day to keep packing moist. 1

Management of Anticoagulation

Do not discontinue anticoagulant or antiplatelet agents before attempting first-line local measures (compression, vasoconstrictors, cautery, packing) unless hemorrhage is life-threatening. 1, 4

• Continue aspirin in patients at high cardiovascular risk (recent myocardial infarction or coronary stents) because survival benefit outweighs bleeding risk. 1, 4
• For life-threatening hemorrhage only, consider reversal agents: warfarin (4-factor prothrombin complex concentrate provides faster INR correction than fresh-frozen plasma), dabigatran (idarucizumab), other direct oral anticoagulants (4-factor PCC), unfractionated heparin/LMWH (protamine sulfate). 1

Criteria for ENT Referral

Refer to otolaryngology when:

• Bleeding persists despite appropriate nasal packing. 1, 4
• Recurrent epistaxis occurs despite correct local treatment and preventive measures. 1, 4
• Three unsuccessful packing attempts have been made. 1
• Bilateral recurrent nosebleeds with oral/nasal mucosal telangiectasias or family history suggest hereditary hemorrhagic telangiectasia. 1, 4
• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes suggests a mass lesion. 4, 5
• Persistent or recurrent bleeding not controlled by packing or cautery requires evaluation for surgical arterial ligation or endovascular embolization. 1, 4

Advanced Surgical Options

• Endoscopic sphenopalatine artery ligation achieves 97% success rate compared with 62% for conventional packing, with recurrence rates <10% versus ~50% for packing. 1, 4
• Endovascular embolization has 80% success rate with comparable efficacy to surgical methods. 1, 3

Prevention of Recurrence

After hemostasis, apply petroleum jelly or saline-based nasal gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and reduce recurrence. 1, 4

• Recommend frequent saline nasal sprays throughout the day and use of a humidifier in dry environments. 1, 4
• Advise patients to avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for at least 7–10 days post-treatment. 1, 4

Common Pitfalls to Avoid

• Premature release of compression before the full 10–15 minutes leads to treatment failure. 1, 4
• Do not aggressively lower blood pressure acutely during active epistaxis, as excessive reduction can cause renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension. 1, 5
• Do not routinely discontinue NSAIDs or anticoagulation for epistaxis; most cases resolve with local measures alone. 1
• Do not overlook hereditary hemorrhagic telangiectasia screening in patients with recurrent bilateral epistaxis. 1

Red-Flag Signs Requiring Immediate Escalation

• Active bleeding despite correctly placed packing. 1
• Hemodynamic instability (tachycardia, hypotension, syncope, orthostatic changes). 1, 4
• Fever >38.3°C (101°F). 1
• New visual disturbances. 1
• Bleeding duration >30 minutes within a 24-hour period. 1, 5