Management of Frequent Nosebleeds (Epistaxis)

Initial Assessment and Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends immediately assessing whether the patient requires prompt management based on bleeding severity, airway compromise risk, and hemodynamic stability 1, 2
Document factors that increase bleeding frequency or severity, including personal/family history of bleeding disorders, use of anticoagulant/antiplatelet medications, and intranasal drug use 1
Position the patient sitting upright with head slightly tilted forward to prevent blood from entering the airway or stomach 3

Apply firm sustained compression to the lower third of the nose for 5 minutes or longer, which resolves most nosebleeds and should be the initial intervention 2
After removing any blood clots, perform anterior rhinoscopy to identify the bleeding site 1, 4

For identified bleeding sites, use appropriate interventions including topical vasoconstrictors (oxymetazoline, phenylephrine) which resolve 65-75% of nosebleeds 5
Nasal cautery (chemical or electrical) after proper anesthetization of the site 1, 4
Moisturizing or lubricating agents to prevent recurrence 1, 5

Perform nasal endoscopy to examine the nasal cavity and nasopharynx when bleeding is difficult to control, there is concern for unrecognized pathology, or patient has recurrent nasal bleeding despite prior treatment with packing or cautery 1, 5, 4
Evaluate candidacy for surgical arterial ligation or endovascular embolization for persistent or recurrent bleeding not controlled by packing or cauterization 1

In anticoagulated patients, initiate first-line treatments before considering transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications 1, 4
Assess for nasal and oral mucosal telangiectasias in patients with history of recurrent bilateral nosebleeds or family history of recurrent nosebleeds 1

Educate patients and caregivers about preventive measures (nasal moisturization, humidification), home treatment techniques, and indications to seek additional medical care 1, 5
Recommend regular application of nasal emollients or petroleum jelly to prevent mucosal dryness 5

Document outcome of intervention within 30 days or document transition of care for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 1, 5, 4

The American Heart Association recommends positioning the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 6
Firm, continuous compression to the soft lower third of the nose for a full 10-15 minutes is recommended to resolve the vast majority of cases 6
Patients should be instructed to breathe through their mouth and spit out any blood rather than swallowing it 6

Nasal cautery (chemical or electrical) is more effective than nasal packing when a bleeding site can be clearly visualized, according to the American Academy of Otolaryngology-Head and Neck Surgery 7
Avoid bilateral cautery simultaneously due to risk of septal perforation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 7

The American Heart Association recommends that patients on anticoagulants or antiplatelets initiate first-line treatments (compression, vasoconstrictors, moisturizers) before considering anticoagulation reversal or withdrawal, and seek medical evaluation unless bleeding has completely stopped 6

Epistaxis that does not stop after 15 minutes of continuous manual pressure requires immediate medical attention, according to the American Heart Association 6
Patient becomes lightheaded or shows signs of hemodynamic instability, as recommended by the American Heart Association 6
Epistaxis due to trauma with signs of brain injury, nasal deformity, or facial fracture requires immediate medical attention, according to the American Heart Association 6

Evaluate candidacy for surgical arterial ligation or endovascular embolization for persistent bleeding not controlled by packing or cauterization, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 7