Epistaxis Management

Initial Intervention

• The American Academy of Otolaryngology-Head and Neck Surgery recommends that patients with epistaxis should be seated with their head slightly forward to prevent blood from flowing into the airway or stomach, and apply continuous pressure to the soft lower part of the nose for 10-15 minutes 1, 2, 3
• Patients should breathe through their mouth and spit out blood instead of swallowing it, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
• Compression alone is often sufficient in the majority of cases, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 3

Pressure Application

• If pressure application is insufficient, the nasal cavity should be cleaned of clots and a topical vasoconstrictor (such as oxymetazoline or phenylephrine) should be applied, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3
• Vasoconstrictor application can stop bleeding in 65-75% of cases treated in the emergency department, according to the American Academy of Otolaryngology-Head and Neck Surgery 3

After Bleeding Control

• To prevent recurrence, moisturizing or lubricating agents (such as petroleum jelly) should be applied to the nasal mucosa, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2, 3
• Regular use of saline sprays is recommended to keep the nasal mucosa moist, according to the American Academy of Otolaryngology-Head and Neck Surgery 2, 3

Advanced Treatment

• If bleeding does not stop after 15 minutes of continuous pressure, nasal packing should be applied, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
• In patients taking anticoagulants or antiplatelet medications, absorbable tamponade material should be used, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 4

Recurrent or Persistent Bleeding

• Endoscopic evaluation can be used to examine the nasal cavity and nasopharynx, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
• In cases of recurrent or persistent bleeding, evaluation for arterial ligation or endovascular embolization should be considered, according to the American Academy of Otolaryngology-Head and Neck Surgery 1

Epistaxis Management

Initial Treatment and Prevention

• The American Academy of Otolaryngology-Head and Neck Surgery recommends that vasoconstrictor application stops bleeding in 65-75% of cases treated in the emergency department, with over-the-counter options including oxymetazoline or phenylephrine, but may be associated with increased risk of cardiac or systemic complications in susceptible patients 5
• Keeping the nose moist with nasal saline and humidifier use helps prevent future nosebleeds, and patients should avoid picking or rubbing the nose to allow healing 5

Advanced Treatment Options

• Electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) when an anterior bleeding site is identified, but may be painful despite anesthesia and can damage the nasal lining if performed too vigorously 5
• Nasal endoscopy can localize the bleeding site in 87-93% of cases, and is useful in evaluating patients with epistaxis, especially for posterior epistaxis which can occur from the septum or lateral nasal wall 5

Surgical Management and Follow-Up

• Recurrence rates vary, with less than 10% for surgical artery ligation or embolization, versus 50% for nasal packing 6
• Routine follow-up is recommended for patients who have undergone invasive treatments for epistaxis to assess for complications and recurrent bleeding, and patients should be educated about secondary symptoms requiring additional follow-up 6
• Adequate follow-up allows assessment for underlying conditions when treatments are ineffective or bleeding recurs, and document outcomes within 30 days to improve individual patient care and provide research opportunities 6

Epistaxis Management

Initial Assessment and Treatment

• The American Academy of Otolaryngology-Head and Neck Surgery recommends triage for severity, distinguishing patients requiring prompt management from those who do not, based on factors such as bleeding duration, hemodynamic instability, and history of hospitalization for epistaxis 7, 8
• The American Academy of Otolaryngology-Head and Neck Surgery suggests applying firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped, as this can be performed by the patient, caregiver, or clinician 7, 8
• Compression alone resolves the vast majority of anterior epistaxis cases, according to the American Academy of Otolaryngology-Head and Neck Surgery 8

Advanced Interventions

• The American Academy of Otolaryngology-Head and Neck Surgery indicates that nasal packing is necessary for failure of compression, vasoconstrictors, and cautery, life-threatening bleeding, or posterior bleeding source 8
• The American Academy of Otolaryngology-Head and Neck Surgery recommends using resorbable packing materials for patients on anticoagulants 8

Prevention of Recurrence and Documentation

• The American Academy of Otolaryngology-Head and Neck Surgery suggests applying petroleum jelly or lubricating agents to nasal mucosa once bleeding stops to prevent recurrence 7
• The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting factors increasing bleeding frequency or severity, such as personal or family history of bleeding disorders, anticoagulant or antiplatelet use, and intranasal drug use 7

Management of Epistaxis in Anticoagulated Patients

Initial Evaluation and Stratification

• The American Academy of Otolaryngology-Head and Neck Surgery recommends that patients with epistaxis and significant risk factors, such as recent nasal trauma with septal fracture, should be evaluated for hemodynamic stability and managed accordingly 9
• Patients with epistaxis who are hemodynamically stable, without significant blood loss, and have controlled bleeding with local measures, do not require reversal of anticoagulation 10, 9

Immediate Management

• The use of posterior nasal packing with a Foley catheter and acid tranexamic-soaked gauze is indicated for posterior epistaxis that does not respond to compression, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 10, 11
• The American Academy of Otolaryngology-Head and Neck Surgery guidelines suggest that material used for nasal packing in anticoagulated patients should be reabsorbable to avoid trauma during removal 10, 11

Anticoagulation Management

• The American Academy of Otolaryngology-Head and Neck Surgery recommends that anticoagulation should not be reversed in patients with epistaxis who are hemodynamically stable and have controlled bleeding with local measures, unless there is a life-threatening bleed 10, 11
• The decision to restart anticoagulation should be made on an individual basis, balancing the risk of thrombosis and bleeding, and typically occurs within 24-48 hours after confirmation of hemostasis 12

Prevention of Recurrence

• The American Academy of Otolaryngology-Head and Neck Surgery recommends that patients with epistaxis should be educated on the importance of follow-up, signs of alarm, and preventive measures, such as applying nasal lubricants and using humidifiers 10, 11
• Patients should avoid nasal manipulation, vigorous nose-blowing, and the use of nasal decongestants for at least 7-10 days after removal of nasal packing 9

Escalation of Treatment

• If nasal packing fails or there is recurrent bleeding, evaluation for surgical ligation or endovascular embolization should be considered, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 9
• Endoscopic nasal examination can help identify the exact site of bleeding and guide further management, such as cauterization or embolization 10, 9

Epistaxis Management Guidelines

Immediate First-Line Management

• The American Academy of Otolaryngology-Head and Neck Surgery recommends applying continuous pressure to the soft lower third of the nose for a minimum of 10-15 minutes, and having the patient breathe through their mouth and spit out blood rather than swallowing it 13
• The American Academy of Otolaryngology-Head and Neck Surgery suggests applying topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril, and resuming firm compression for another 5-10 minutes after applying the vasoconstrictor 13

Advanced Interventions When Compression Fails

• The American Academy of Otolaryngology-Head and Neck Surgery indicates that nasal packing is used when bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors, and for life-threatening bleeding or when a posterior bleeding source is suspected 13
• For patients on anticoagulants or antiplatelet medications, the American Academy of Otolaryngology-Head and Neck Surgery recommends using only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal, while for patients without bleeding risk factors, either resorbable or non-resorbable materials may be used 13

Epistaxis Management

Introduction to Evidence-Based Practices

• The American Heart Association, as published in Circulation, notes that current evidence does not support the use of ice packs as a first aid intervention for acute epistaxis, as it does not significantly change nasal blood flow or volume 14

Advanced Surgical Options

• Endoscopic sphenopalatine artery ligation has a 97% success rate, outperforming conventional packing which has a 62% success rate 14
• Endovascular embolization has an 80% success rate, with comparable efficacy to surgical methods, and both have lower recurrence rates (<10%) compared to nasal packing (50%) 14

Management of Epistaxis in Patients Taking NSAIDs

Special Considerations for NSAID-Related Epistaxis

• The American Academy of Family Physicians recommends that patients taking NSAIDs who develop epistaxis should be managed with the same standard epistaxis management protocol without discontinuing the NSAID unless bleeding cannot be controlled with local measures, recognizing that NSAIDs cause significant platelet dysfunction that increases bleeding risk 15
• NSAIDs produce significant platelet dysfunction through antiplatelet effects, which should be considered in the multifactorial etiology of epistaxis, and the antiplatelet effects are in addition to any direct mucosal effects 15
• The American Academy of Family Physicians advises against routinely discontinuing NSAIDs for epistaxis, and NSAIDs should be avoided in persons with preexisting platelet defects or thrombocytopenia, but standard epistaxis alone is not an indication to stop 15
• For aspirin specifically, the American Academy of Family Physicians recommends that if the patient is at high risk of cardiovascular events, aspirin should be continued despite epistaxis 15
• For other NSAIDs, the American Academy of Family Physicians suggests that if discontinuation is necessary perioperatively or for severe bleeding, withhold for five elimination half-lives 15

Critical Pitfalls to Avoid

• Premature NSAID discontinuation should be avoided, as most epistaxis resolves with local measures alone, according to the American Academy of Family Physicians 15
• The American Academy of Family Physicians warns against stopping aspirin in high-risk cardiovascular patients, as the survival benefits outweigh bleeding risks in patients with recent MI or stents 15

Anticoagulation Interaction Warning

• The American Academy of Family Physicians notes that when NSAIDs are combined with anticoagulants, there is a three- to sixfold increased risk of GI bleeding, and this principle extends to mucosal bleeding sites 15
• If a patient is on both NSAIDs and warfarin, the American Academy of Family Physicians expects INR to increase by up to 15% 15

Epistaxis Management

Initial Assessment and Treatment

• After initial compression, clean the nasal cavity of blood clots by suction or gentle nose blowing, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 16
• Perform anterior rhinoscopy to identify the bleeding source after clot removal, according to the American Academy of Otolaryngology-Head and Neck Surgery 16
• Nasal endoscopy localizes the bleeding site and is indicated if recurrent bleeding occurs despite prior treatment, or if anterior rhinoscopy fails to identify the source, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 16

Definitive Treatment Options

• Avoid bilateral simultaneous septal cautery as it increases the risk of septal perforation, as warned by the American Academy of Otolaryngology-Head and Neck Surgery 17

Indications for Specialist Referral

• Recurrent bleeding despite appropriate treatment requires specialist referral, as indicated by the American Academy of Otolaryngology-Head and Neck Surgery 16

Management of Uncontrolled Epistaxis

Advanced Interventions for Persistent or Recurrent Bleeding

• For persistent or recurrent bleeding not controlled by packing or cautery, evaluate candidacy for surgical arterial ligation or endovascular embolization, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 18
• Surgical options, including endoscopic sphenopalatine artery ligation, have a high success rate, with a 97% success rate compared to 62% for conventional packing, according to the American Academy of Otolaryngology-Head and Neck Surgery 18
• Endovascular embolization has an 80% success rate with recurrence rates less than 10% compared to 50% for nasal packing, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 18

Special Consideration: Hereditary Hemorrhagic Telangiectasia

• Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds, as this may indicate Hereditary Hemorrhagic Telangiectasia requiring specialized management, according to the American Academy of Otolaryngology-Head and Neck Surgery 18

Patient Education

• Provide instructions on post-procedure care if packing is placed, including the use of saline nasal sprays and humidifiers, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 18

Management of Ongoing Epistaxis Despite Nasal Packing

Immediate Assessment and Stabilization

• Active bleeding from nose or mouth despite packing, hemodynamic instability, fever over 101°F, vision changes, shortness of breath, or facial swelling are key warning signs requiring urgent intervention in patients with ongoing epistaxis, according to the American Academy of Otolaryngology-Head and Neck Surgery 19

Post-Intervention Monitoring

• Applying nasal saline spray frequently throughout the day to keep packing moist is recommended for patients with nasal packing in place, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 19

Management of Chronic Nosebleeds

Initial Assessment and Risk Stratification

• The American Academy of Otolaryngology-Head and Neck Surgery recommends distinguishing whether patients with chronic nosebleeds require prompt management based on active bleeding with hemodynamic instability, airway compromise from blood in the oropharynx, and other critical risk factors 20
• Documenting critical risk factors, such as recurrent bilateral nosebleeds, is essential for increasing bleeding frequency or severity, according to the American Academy of Otolaryngology-Head and Neck Surgery 20

Advanced Treatment for Persistent Bleeding

• The American Academy of Otolaryngology-Head and Neck Surgery suggests using only resorbable materials, such as Nasopore, Surgicel, or Floseal, for nasal packing in patients on anticoagulants or antiplatelets to avoid trauma during removal 20
• Post-packing patient education must include the type of packing placed, timing and plan for removal, and warning signs requiring immediate reassessment, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 20

Evaluation for Underlying Pathology

• The American Academy of Otolaryngology-Head and Neck Surgery recommends performing nasal endoscopy when bleeding is difficult to control, recurrent bleeding occurs despite prior treatment, or concern exists for unrecognized pathology 20
• Screening for hereditary hemorrhagic telangiectasia (HHT) is necessary for patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds, according to the American Academy of Otolaryngology-Head and Neck Surgery 20

Surgical and Interventional Options for Refractory Cases

• The American Academy of Otolaryngology-Head and Neck Surgery suggests evaluating candidacy for definitive intervention when persistent or recurrent bleeding is not controlled by packing or cauterization, and recurrence rates favor surgical intervention over repeated packing 20

Management of Spontaneous Epistaxis

Differential Diagnosis and Risk Factors

• The American Academy of Otolaryngology-Head and Neck Surgery suggests screening for bleeding disorders, such as easy bruising, prolonged bleeding from minor cuts, and family history of bleeding disorders, in patients with spontaneous epistaxis 21
• Medication use, including NSAIDs, aspirin, anticoagulants, antiplatelet agents, and intranasal drug use, should be considered as a potential cause of epistaxis, according to the American Academy of Otolaryngology-Head and Neck Surgery 21

When to Escalate Care

• The American Academy of Otolaryngology-Head and Neck Surgery recommends returning immediately if bleeding persists after 15 minutes of continuous proper compression, bleeding duration exceeds 30 minutes over a 24-hour period, or signs of hemodynamic instability are present 21
• Patients with recurrent episodes of epistaxis, defined as more than 3 recent episodes, warrant evaluation, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 21

Documentation and Risk Stratification

• The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting the duration of bleeding episode, response to compression, medication history, personal or family history of bleeding disorders, and blood pressure measurement to assess severity and guide management 21

Management of Persistent Epistaxis in Elderly Patients on Aspirin

Definition of Severe Epistaxis

• Bleeding that persists for more than 30 minutes within a 24‑hour period is classified as severe and warrants prompt medical evaluation. American Academy of Otolaryngology‑Head and Neck Surgery (AAO‑HNS) recommendation. 22

Initial Assessment

• Elderly patients (≥ 75 years) presenting with continuous nasal bleeding should be triaged urgently because age‑related anatomic changes increase the likelihood of posterior sources and complications. AAO‑HNS guidance. 22

First‑Line Local Measures

Compression and Vasoconstriction

• Apply firm, sustained pressure to the soft lower third of the nose for 10–15 minutes without intermittent checking for cessation of bleeding. AAO‑HNS protocol. 23

Endoscopic Evaluation

• After clot removal, perform anterior rhinoscopy to locate the bleeding source. AAO‑HNS recommendation. 23
• If anterior rhinoscopy is inconclusive or bleeding is difficult to control, proceed to nasal endoscopy of the nasal cavity and nasopharynx. AAO‑HNS guidance. [22][23]

Cautery (when a focal source is identified)

• Anesthetize the identified site with topical lidocaine before cautery. AAO‑HNS instruction. 24
• Limit cautery application strictly to the active bleeding point to minimize mucosal injury. AAO‑HNS recommendation. [23][24]

Nasal Packing (if bleeding persists)

• Initiate nasal packing when compression, vasoconstrictors, and cautery fail to achieve hemostasis. AAO‑HNS guideline. 23
• Use only resorbable/absorbable packing materials (e.g., Nasopore, Surgicel, Floseal) in patients receiving antiplatelet therapy to avoid trauma during removal. AAO‑HNS recommendation. 23
• Non‑resorbable packing devices should be avoided in individuals on antiplatelet medications. AAO‑HNS directive. 23

Aspirin Management

• Do not discontinue aspirin solely for the treatment of epistaxis; continuation is advised unless bleeding is life‑threatening. AAO‑HNS position. 23
• The AAO‑HNS explicitly recommends that first‑line local interventions (compression, vasoconstrictors, cautery, packing) be attempted before considering withdrawal of antiplatelet agents in the absence of massive hemorrhage, hemodynamic instability, or airway compromise. AAO‑HNS guidance. 23

Advanced Therapies (for refractory cases)

• Topical tranexamic acid (TXA) applied to the nasal mucosa shortens time to hemostasis (average 6.7 min vs 11.5 min with standard packing) and lowers recurrence rates (6 % vs 20 %) in patients on antiplatelet drugs. AAO‑HNS evidence. 24

Referral and Escalation Criteria

• Refer to otolaryngology if bleeding continues despite appropriate nasal packing. AAO‑HNS referral indication. 23
• Refer if recurrent epistaxis occurs despite correct local treatment and preventive measures. AAO‑HNS recommendation. 23
• Refer patients with bilateral recurrent nosebleeds for evaluation of possible hereditary hemorrhagic telangiectasia. AAO‑HNS suggestion. 23
• Refer for assessment of surgical arterial ligation or endovascular embolization when persistent bleeding necessitates advanced intervention. AAO‑HNS guideline. 23

Acute Epistaxis Initial Management Guidelines (American Academy of Otolaryngology‑Head and Neck Surgery)

Direct Nasal Compression

• The American Academy of Otolaryngology‑Head and Neck Surgery recommends initiating treatment with firm, sustained compression of the soft lower third of the nose for 10–15 minutes without intermittent checking; if bleeding persists, a topical vasoconstrictor should be applied. 25
• While the compression is applied, the patient should breathe through the mouth and expectorate blood rather than swallowing it. 25

Baseline Blood Pressure Assessment

• A baseline blood‑pressure measurement should be obtained because ≈33 % of patients with epistaxis have underlying hypertension that may not yet be diagnosed. 25

Indications for Nasal Packing

• The American Academy of Otolaryngology‑Head and Neck Surgery advises nasal packing when any of the following are present:

Documentation Requirements

• Documentation must include a personal and family history of bleeding disorders to facilitate risk stratification and future management planning. 25

Management of Anterior Epistaxis in Elderly Patients with Nasal Congestion

Immediate Bleeding Control

• Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking for cessation – this first‑line maneuver resolves the vast majority of anterior epistaxis in elderly patients with congestion‑related mucosal irritation; premature release is a common cause of treatment failure. American Academy of Otolaryngology‑Head and Neck Surgery 26

Pharmacologic Adjuncts

• Topical oxymetazoline or phenylephrine spray (2 sprays into the bleeding nostril) stops bleeding in 65–75 % of emergency‑department presentations, thereby avoiding the need for nasal packing in most cases. American Academy of Otolaryngology‑Head and Neck Surgery 26
• Before using topical vasoconstrictors, obtain a baseline blood pressure because approximately one‑third of epistaxis patients are undiagnosed hypertensive; vasoconstrictors carry an increased risk of cardiac or systemic complications in this subgroup. American Academy of Otolaryngology‑Head and Neck Surgery 26
• Avoid repeated or prolonged use of topical vasoconstrictors, as this can precipitate rhinitis medicamentosa, loss of efficacy, and worsening nasal obstruction. American Academy of Otolaryngology‑Head and Neck Surgery 26

Prevention and Mucosal Moisturization

• After hemostasis, apply petroleum jelly or a nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and reduce recurrence. American Academy of Otolaryngology‑Head and Neck Surgery 26
• Use saline nasal sprays frequently throughout the day to keep the nasal mucosa moist in elderly patients prone to dryness‑related bleeding. American Academy of Otolaryngology‑Head and Neck Surgery 26
• Recommend the use of a humidifier in dry environments, since dry heat and abrupt temperature changes create fragile, hyperemic nasal mucosa that bleeds easily. American Academy of Otolaryngology‑Head and Neck Surgery 26

Escalation to Procedural Intervention

• 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, or (3) a posterior bleeding source is suspected. American Academy of Otolaryngology‑Head and Neck Surgery 26

Endoscopic Evaluation

• If anterior rhinoscopy does not identify the bleeding source, perform nasal endoscopy; this technique localizes the bleeding site in 87–93 % of cases, facilitating targeted treatment. American Academy of Otolaryngology‑Head and Neck Surgery 26