Initial Management of Epistaxis

Assessment and Immediate Management

• The American Academy of Otolaryngology-Head and Neck Surgery recommends firm sustained compression to the lower third of the nose for 5 minutes or longer as the initial management for a patient presenting with epistaxis 1, 2
• Clinicians should distinguish patients who require prompt management from those who do not at the time of initial contact 3, 1
• For active bleeding, assess for airway compromise from bleeding into the oropharynx 4
• For active bleeding, assess for hemodynamic instability due to blood loss 4
• For active bleeding, assess the severity of bleeding (minor vs. severe) 3

First-Line Treatment: Nasal Compression

• Apply firm sustained compression to the lower third (soft part) of the nose for at least 5 minutes 1, 2
• This simple measure stops bleeding in the majority of cases and should be attempted before more invasive interventions 1, 2

Further Management Based on Response

• If bleeding continues after compression, perform anterior rhinoscopy after removing any blood clots to identify the bleeding site 5
• The source of bleeding is commonly from Kiesselbach's plexus in the anterior nasal septum 6
• Topical vasoconstrictors (e.g., oxymetazoline, phenylephrine) can stop 65-75% of nosebleeds 6
• Consider nasal cautery (chemical or electrical) for localized bleeding sites 6, 7
• Use moisturizing or lubricating agents after bleeding is controlled to prevent recurrence 6
• If bleeding cannot be controlled with the above measures, apply nasal packing 5
• Use resorbable packing for patients with suspected bleeding disorders or those on anticoagulant/antiplatelet medications 5

Special Considerations

• Document factors that increase bleeding risk, including personal or family history of bleeding disorders 8, 9
• Document factors that increase bleeding risk, including use of anticoagulant or antiplatelet medications 8, 9
• Document factors that increase bleeding risk, including intranasal drug use 8, 9
• Document factors that increase bleeding risk, including hypertension, prior nasal surgery, or trauma 8

Common Pitfalls to Avoid

• Premature termination of compression should be avoided, and compression should be maintained for at least 5 minutes without checking if bleeding has stopped 1, 2
• Overlooking anticoagulant medications can lead to inadequate management, and first-line treatments should be initiated prior to considering reversal or withdrawal of anticoagulation 9, 5

Patient Education

• Instruct patients on proper home management techniques for future episodes 9
• Advise on preventive measures such as nasal saline sprays and humidification 6
• Provide clear guidance on when to seek additional medical care 9