Management of Epistaxis

Initial Assessment and Treatment

Apply firm, sustained compression to the lower third of the nose for at least 5 minutes, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Patients should breathe through the mouth and spit out any blood during compression, as recommended by the American Heart Association and the American Academy of Otolaryngology-Head and Neck Surgery 3, 1, 2
First-line treatment for epistaxis in patients with cardiovascular disease should include proper nasal compression for 10-15 minutes while sitting upright with the head tilted slightly forward, followed by escalation to resorbable nasal packing if bleeding persists, especially in patients on anticoagulant or antiplatelet medications 2
Topical vasoconstrictors such as oxymetazoline nasal spray have a 65% success rate in controlling epistaxis, according to the American Academy of Otolaryngology-Head and Neck Surgery 2
Topical tranexamic acid (TXA) can be applied to promote hemostasis, controlling bleeding within 10 minutes in 71% of patients, as noted by the American Academy of Otolaryngology-Head and Neck Surgery 1
A dose of 1000 mg of tranexamic acid appears more effective than 500 mg for topical application in promoting hemostasis 4

Apply nasal saline gel or spray 1-3 times daily to moisturize nasal tissues, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
Use a humidifier at bedside to maintain a humid environment, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 2
Avoid digital trauma (nose picking) to prevent further irritation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
Avoid vigorous nose blowing to prevent bleeding, as advised by the American Academy of Otolaryngology-Head and Neck Surgery 2
Patients should be instructed on post-procedure care, including avoiding straining, lifting over 10 pounds, bending over, and exercising, sleeping with head slightly elevated, avoiding nose blowing if packing is in place, and using nasal saline sprays to keep the nose moist, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
Monitor for infection and respiratory effects of nasal obstruction, especially in patients with compromised immune systems due to vasculitis treatment, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2

Patients with risk factors such as anticoagulant or antiplatelet medications, blood-clotting disorders, or signs of hypovolemia should seek immediate medical attention, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery and the American Heart Association 3, 1, 2
For patients on dual antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with prescribing physician, as recommended by the European Heart Journal and the European Society of Cardiology 5
Documenting factors that increase bleeding severity, including anticoagulant/antiplatelet use, bleeding disorders, or intranasal drug use, is recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1

Schedule follow-up within 3-5 days to assess for recurrence, and provide patients with clear instructions on when to seek emergency care, such as bleeding lasting >30 minutes or signs of hypovolemia, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2
Documentation of the outcome within 30 days is recommended for patients who experienced significant epistaxis requiring intervention, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 2
Consider surgical options such as endoscopic arterial ligation or endovascular embolization for patients with persistent/recurrent bleeding not controlled by packing or cauterization, with success rates of 97% and ~80%, respectively, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2