Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

active epistaxis: initial measures

1st line – clear nose and apply pressure ± vasoconstrictor

Back
INITIAL
|
active epistaxis: initial measures
1st line – 

clear nose and apply pressure ± vasoconstrictor

Advise the patient to clear their nose of blood because clotted blood may promote fibrinolysis.[5] They should hold their head in a "sniffing" position, flexed slightly forward.[5]

Apply firm and sustained pressure to the lower third of the nose (the entire lower compressible cartilage) with or without assistance from a parent or caregiver for at least 5 minutes.​[3][5]​​ A nose clip can be used if available and tolerated by the patient.​[3][5]

Consider applying topical vasoconstrictor (decongestant), such as oxymetazoline, using a nasal spray or by inserting impregnated cotton balls or pledgets into the nose.​[3][5]​​ Apply the vasoconstrictor for both diagnostic and therapeutic purposes, to help visualize the epistaxis site and encourage hemostasis. A decongestant will also shrink mucosal thickness, allowing more open nasal space should placement of a pack be required. This can reduce mucosal trauma incurred during insertion of a pack and thereby decrease secondary bleeding sites from disrupted mucus membrane.

Consider – resuscitation and supportive measures

Back
INITIAL
|
active epistaxis: initial measures
Consider – 

resuscitation and supportive measures

Treatment recommended for SOME patients in selected patient group

Prompt assessment of bleeding severity will assist in directing the patient to the proper clinical site for management. Few studies address the most appropriate setting for care of nosebleeds.[5]

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of hemodynamic compromise. Such patients need urgent resuscitation in the hospital.[5] Patients may be more prone to hemodynamic compromise if: 1) there is severe bleeding, indicated by a large volume of blood, prolonged bleeding, bleeding from both sides of the nose, or bleeding from the mouth. Severe bleeding may be more likely with a history of hospitalization for nosebleed, prior blood transfusion for nosebleed, or more than 3 recent nosebleeds; 2) the patient is older; or 3) the patient is ill or frail. Comorbidities that may impede the patient's response to a bleed include hypertension, cardiopulmonary disease, anemia, bleeding disorders, and liver or kidney disease.[5]

Oxygen supplementation, intravenous access, urgent complete blood count, platelets, clotting studies, and blood type for transfusion are required, along with the maintenance of airway, breathing, and circulation (ABC).

Consider – tranexamic acid

Back
INITIAL
|
active epistaxis: initial measures
Consider – 

tranexamic acid

Treatment recommended for SOME patients in selected patient group

Consider administering tranexamic acid according to local protocols.[32]

Tranexamic acid can be administered topically, orally, or parenterally for epistaxis.[5][32]​ The American Academy of Otolaryngology guideline does not make any recommendations regarding the use of topical or oral tranexamic acid.[5]​ However, there is evidence supporting its effectiveness in controlling epistaxis and topical application of tranexamic acid is increasingly used in the emergency department.[34][35][36][37]​ In the acute setting, a cotton pledget may be soaked in the intravenous formulation and applied to the bleed site.[33][34]

Primary options

tranexamic acid: children and adults: consult specialist for guidance on dose

Consider – treatment of underlying cause

Back
INITIAL
|
active epistaxis: initial measures
Consider – 

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

Initial assessment may reveal an obvious underlying cause or exacerbating factor.

Underlying causes, such as septal deviation or perforation, may become apparent.[5] Treat local causes such as foreign body, polyp, and ulceration to the skin around the nose accordingly.[44]

Coagulation disorders may require management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Provide a post-treatment nosebleed instruction sheet.

ACUTE

active epistaxis: persistent bleeding precluding identification of bleeding site

1st line – anterior nasal packing

Back
ACUTE
|
active epistaxis: persistent bleeding precluding identification of bleeding site
1st line – 

anterior nasal packing

If you cannot identify the exact site of the bleeding, treat active bleeding that is not controlled by nasal pressure with nasal packing.[5][38]​ With adequate resources, you can perform anterior nasal packing in outpatient offices or emergency departments.[5]

Resorbable packing is generally preferred over nonresorbable packing, especially in patients with a suspected bleeding disorder, vascular abnormalities such as hereditary hemorrhagic telangiectasia, children, or those using anticoagulants or antiplatelet agents. Resorbable packing does not need to be removed. If bleeding is not controlled with resorbable packing, treatment may be advanced to nonresorbable packing.[5][10]

Resorbable packing materials include oxidized regenerated cellulose, purified porcine skin and gelatin granules, and hemostatic gelatin thrombin matrices.[5][39][40]

Choose the specific packing based on local availability and experience; there is limited comparative evidence to support the use of one material over any other.[5]​

Nonresorbable packing includes a variety of gauze dressings, polymers, and inflatable balloons.[5]​ Traditional nonresorbable packing involves horizontal layering of 12-mm (half-inch) cotton gauze saturated with petroleum jelly or antibiotic ointment.[5] The newer options are more convenient and easier to position than traditional packing, particularly for physicians who infrequently place nasal packing. Because of concerns that packing material may become displaced, some patients are managed in the hospital, but uncomplicated patients with nosebleeds controlled with anterior packing can usually be managed as outpatients, depending on local protocols.[5][48]​

Remove all types of nonresorbable packings at some point after achieving sustained control of nasal hemorrhage.[5] The nonresorbable pack is usually removed at 48-72 hours.[5] This allows: 1) healing of the original bleeding site; 2) remucosalization of any secondary sites from pack insertion trauma; 3) regeneration of functional platelets or clotting factors in patients on drugs that impair coagulation. 

As epistaxis generally originates on one side, packing is unilateral. Bilateral packing is only formally indicated in the unusual situation of true hemorrhage from both sides, or when the history and examination fail to identify whether the bleeding is from the right or the left. In practice, nonspecialists often resort to bilateral packing as it is difficult to determine accurately the true site of the bleed. Bilateral packing will also improve pressure on an identified bleeding source by providing counter pressure on the nasal septum.

Insertion of an anterior nasal pack
Insertion of an anterior nasal pack

Demonstrates insertion of an inflatable anterior nasal pack and a nasal tampon.

Consider – antibiotic therapy

Back
ACUTE
|
active epistaxis: persistent bleeding precluding identification of bleeding site
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Although controversial, consider oral antibiotics on an individual basis while packing remains in place.[5] Infection risks from nasal packing include local infection, bacteremia, and (rarely) toxic shock syndrome, although most studies reporting these complications involve the use of nonresorbable packing only.[5][49]

Select antibiotics that have activity against typical sinusitis pathogens and Staphylococcus aureus.[5] Appropriate antibiotics include amoxicillin/clavulanate or cefuroxime. Consider sulfamethoxazole/trimethoprim or a macrolide (e.g., clarithromycin, azithromycin) in the case of allergy to penicillin or cephalosporins.[50]​ 

Although there is little evidence of protective benefit from toxic shock syndrome by application of topical antibiotic ointment (e.g., mupirocin), its use to lubricate packing and reduce trauma is reasonable and commonplace.[5]

Primary options

amoxicillin/clavulanate: children <3 months of age and <40 kg body weight: 30 mg/kg/day orally given in 2 divided doses for 5-7 days; children ≥3 months of age and <40 kg body weight: 25-45 mg/kg/day orally given in 2 divided doses or 20-40 mg/kg/day orally given in 3 divided doses for 5-7 days; children ≥3 months of age and ≥40 kg body weight and adults: 500-875 mg orally twice daily or 250-500 mg orally three times daily for 5-7 days

More

or

cefuroxime axetil: children: 20-30 mg/kg/day orally given in 2 divided doses for 5-7 days, maximum 1000 mg/day; adults: 250-500 mg orally twice daily for 5-7 days

-- AND --

mupirocin topical: (2% ointment) children and adults: apply generously to saturate nasal packing before placement

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-10 mg/kg/day orally given in 2-4 divided doses for 5-7 days; adults: 160 mg orally twice daily for 5-7 days

More

or

clarithromycin: children ≥6 months of age: 15 mg/kg/day orally given in 2 divided doses for 5-7 days; adults: 250-500 mg orally twice daily for 5-7 days

or

azithromycin: children: 10-12 mg/kg (maximum 500 mg/dose) orally once daily on day 1, followed by 5-6 mg/kg (maximum 250 mg/dose) once daily for 4 days; adults: 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

-- AND --

mupirocin topical: (2% ointment) children and adults: apply generously to saturate nasal packing before placement

Consider – analgesia

Back
ACUTE
|
active epistaxis: persistent bleeding precluding identification of bleeding site
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

Prescribe analgesia, as appropriate, for discomfort. Acetaminophen may provide adequate relief, and has been shown to be effective after ENT procedures including sinus surgery.[51]​ Avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

If pain is not controlled with acetaminophen, treatment may be escalated to a suitable opioid (e.g., acetaminophen/hydrocodone).

Use opioids with caution in children, older patients, and patients who are in shock. Opioids are associated with a risk of addiction, abuse, and misuse which can lead to overdose and potentially death. Risk should be assessed before prescribing, and regularly reassessed during treatment. Opioids may cause life-threatening respiratory depression, especially during treatment initiation or dose titration. Avoid concomitant use of other central nervous system depressants, including alcohol.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

hydrocodone/acetaminophen: children ≥2 years of age: consult specialist for guidance on dose; adults: 2.5 to 10 mg orally every 4-6 hours when required

More

Consider – antiemetic

Back
ACUTE
|
active epistaxis: persistent bleeding precluding identification of bleeding site
Consider – 

antiemetic

Treatment recommended for SOME patients in selected patient group

Give an antiemetic (e.g., ondansetron) for nausea that may be caused by swallowed blood.

Primary options

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required

Consider – resuscitation and supportive measures

Back
ACUTE
|
active epistaxis: persistent bleeding precluding identification of bleeding site
Consider – 

resuscitation and supportive measures

Treatment recommended for SOME patients in selected patient group

Prompt assessment of bleeding severity will assist in directing the patient to the proper clinical site for management. Few studies address the most appropriate setting for care of nosebleeds.[5]

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of hemodynamic compromise. Such patients need urgent resuscitation in the hospital.[5] Patients may be more prone to hemodynamic compromise if: 1) there is severe bleeding, indicated by a large volume of blood, prolonged bleeding, bleeding from both sides of the nose, or bleeding from the mouth. Severe bleeding may be more likely with a history of hospitalization for nosebleed, prior blood transfusion for nosebleed, or more than 3 recent nosebleeds; 2) the patient is older; or 3) the patient is ill or frail. Comorbidities that may impede the patient's response to a bleed include hypertension, cardiopulmonary disease, anemia, bleeding disorders, and liver or kidney disease.[5]

Oxygen supplementation, intravenous access, urgent complete blood count, platelets, clotting studies, and blood type for transfusion are required, along with the maintenance of airway, breathing, and circulation (ABC).

Consider – treatment of underlying cause

Back
ACUTE
|
active epistaxis: persistent bleeding precluding identification of bleeding site
Consider – 

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

Coagulation disorders require management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Local underlying factors may not be visible due to the volume of blood.

Provide a post-treatment nosebleed instruction sheet.

active epistaxis: bleeding site visible

1st line – clear nose ± vasoconstrictor/anesthetic ± cautery

Back
ACUTE
|
active epistaxis: bleeding site visible
1st line – 

clear nose ± vasoconstrictor/anesthetic ± cautery

Remove any blood clot (if present) because clotted blood may promote fibrinolysis.[5] Perform anterior rhinoscopy with a nasal speculum (or otoscope, particularly in children) to identify any bleeding source on the anterior nasal septum, inferior and middle turbinates, floor of the nose, and anterior nasal mucosa.[5]

Consider applying a combination of topical anesthetic (e.g., lidocaine) and vasoconstrictor (decongestant) at this stage.[5] Topical anesthetic makes the procedure more comfortable for the patient and less stressful for the physician. Some physicians prepare a mixture of anesthetic and decongestant in the office or emergency department. For the decongestant, use oxymetazoline rather than phenylephrine as the latter seems more likely to cause hypertension or possibly angina in susceptible patients. Some physicians simply remove the top from a spray bottle of oxymetazoline, add an equal volume of the lidocaine, and replace the top; however, seek specialist advice.

Active bleeding may necessitate rapid alternation between clearing of blood and liberal application of the topical vasoconstrictor and anesthetic.

Next, place small neurosurgical pledgets or strips of cotton well saturated with the mixture horizontally in the nose with bayonet forceps, and leave for 10 to 15 minutes. Ask the patient to compress their nose if necessary. [Figure caption and citation for the preceding image starts]: Nasal pledgets for application of decongestant and local anestheticFrom the collection of David A. Randall, Springfield Ear Nose Throat and Facial Plastic Surgery, MO [Citation ends].com.bmj.content.model.Caption@46915dac

Treat patients with an identified bleeding site with one or more of the following options, as appropriate: topical vasoconstrictors (including oxymetazoline, phenylephrine, epinephrine [adrenaline], or cocaine), nasal cautery, and moisturizing or lubricating agents.[5] Moisturizing and lubricating agents would not usually be used for an active bleed, but would most commonly be applied after cessation of bleeding following cautery and/or vasoconstrictors.[5]

Combinations of several methods are often used; with little evidence comparing options, the American Academy of Otolaryngology guideline refrains from recommending a specific order for these interventions.[5]

The American Academy of Otolaryngology guideline recognizes that the British Rhinological Society recommends that vasoconstrictors should be used prior to cautery, and that cautery of an identified bleeding site should be first-line treatment; however, the US guideline notes that these recommendations were based on limited evidence.[45] Give oxymetazoline or phenylephrine as an intranasal spray or on a cotton pledget, but be cautious in patients with hypertension, cardiac disease, or cerebrovascular conditions, as vasoconstrictors may be associated with cardiac and other complications.

The American Academy of Otolaryngology guideline does not specify a preference for either the chemical or electrical method of cautery.[5] Silver nitrate, chromic acid, or trichloroacetic acid can be used for chemical cautery.[5] However, electrocautery is suggested to be more effective than chemical cautery if the relevant resources and expertise are available.[45]

Perform electrocautery for brisker bleeding that is resistant to silver nitrate treatment. This procedure is usually reserved for the ear, nose, and throat (ENT) specialist. It requires injection of local anesthetic plus vasoconstrictor (e.g., lidocaine with epinephrine), in addition to topical anesthetic. Monopolar and bipolar cautery are both effective. Suction monopolar cautery (if available) evacuates blood and enhances effect, as cautery is ineffective in a wet, blood-filled field. Provide routine post-treatment instructions.

Although most frequently used for office treatment of recurrent epistaxis when bleeding is quiescent, use silver nitrate cautery to treat minor anterior active epistaxis if you have identified a specific site.[5]

Silver nitrate is applied via commercially manufactured sticks or applicators. This compound degrades over time and must be kept in an airtight, lightproof container. Lack of evident activity may indicate the need to use fresher silver nitrate.

The technique for anterior nasal cautery is suggested as follows:

1) Anesthetize the bleeding site adequately; recommendations do not specify a preference for topical or injected anesthetic agents.[5] Lidocaine or tetracaine are common options.[5] Lidocaine can be injected into the nasal septum or administered topically via spray or on pledgets.[5]

2) Apply the cauterizing agent to specific vessels or hemorrhagic areas of concern, and remove excess with a cotton tip applicator.

3) The patient often finds treatment uncomfortable even with adequate application of topical vasoconstrictor and anesthetic.

4) Apply an antibiotic ointment afterward for moisturization.

5) Avoid cautery on both sides of the septum at the same visit. This deprives the septal cartilage of its blood supply (from the mucosal covering) and may result in septal perforation if done bilaterally.[46] Provide routine post-treatment instructions.[7][8][47]

Consider – resuscitation and supportive care

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

resuscitation and supportive care

Treatment recommended for SOME patients in selected patient group

Prompt assessment of bleeding severity will assist in directing the patient to the proper clinical site for management. Few studies address the most appropriate setting for care of nosebleeds.[5]

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of hemodynamic compromise. Such patients need urgent resuscitation in the hospital.[5] Patients may be more prone to hemodynamic compromise if: 1) there is severe bleeding, indicated by a large volume of blood, prolonged bleeding, bleeding from both sides of the nose, or bleeding from the mouth. Severe bleeding may be more likely with a history of hospitalization for nosebleed, prior blood transfusion for nosebleed, or more than 3 recent nosebleeds; 2) the patient is older; or 3) the patient is ill or frail. Comorbidities that may impede the patient's response to a bleed include hypertension, cardiopulmonary disease, anemia, bleeding disorders, and liver or kidney disease.[5]

Oxygen supplementation, intravenous access, urgent complete blood count, platelets, clotting studies, and blood type for transfusion are required, along with the maintenance of airway, breathing, and circulation (ABC).

Consider – treatment of underlying cause

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

Underlying causes, such as septal deviation or perforation, may become apparent.[5] Treat local causes such as foreign body, polyp, and ulceration to the skin around the nose accordingly.[44]

Initial assessment may reveal an obvious underlying cause or exacerbating factor, such as coagulopathy.

Coagulation disorders may require management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Provide a post-treatment nosebleed instruction sheet.

2nd line – unilateral or bilateral anterior packing

Back
ACUTE
|
active epistaxis: bleeding site visible
2nd line – 

unilateral or bilateral anterior packing

Use anterior nasal packing for active bleeding when cautery has been ineffective. Nasal packing requires a minimum of 24 hours in place with at least 48 hours needed for higher risk patients.[10]​ Resorbable packing should be attempted before nonresorbable packing due to patient comfort.[39]

Nonresorbable packing includes a variety of gauze dressings, polymers, and inflatable balloons.[5]

Traditional nonresorbable packing involves horizontal layering of 12-mm (half-inch) cotton gauze saturated with petroleum jelly or antibiotic ointment.[5] The newer options are more convenient and easier to position than traditional packing, particularly for physicians who infrequently place nasal packing. Because of concerns that packing material may become displaced, some patients are managed in the hospital, but uncomplicated patients with nosebleeds controlled with anterior packing can usually be managed as outpatients, depending on local protocols.[5][48]​ Remove all types of nonresorbable packings at some point after achieving sustained control of nasal hemorrhage.[5] The nonresorbable pack is usually removed at 48-72 hours.[5] This allows: 1) healing of the original bleeding site; 2) remucosalization of any secondary sites from pack insertion trauma; 3) regeneration of functional platelets or clotting factors in patients on drugs that impair coagulation. 

As epistaxis generally originates on one side, packing is unilateral. Bilateral packing is only formally indicated in the unusual situation of true hemorrhage from both sides, or when the history and examination fail to identify whether the bleeding is from the right or the left. In practice, nonspecialists often resort to bilateral packing as it is difficult to determine accurately the true site of the bleed. Bilateral packing will also improve pressure on an identified bleeding source by providing counter pressure on the nasal septum.

Insertion of an anterior nasal pack
Insertion of an anterior nasal pack

Demonstrates insertion of an inflatable anterior nasal pack and a nasal tampon.

Consider – antibiotic therapy

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Although controversial, consider oral antibiotics on an individual basis while packing remains in place.[5] Infection risks from nasal packing include local infection, bacteremia, and (rarely) toxic shock syndrome, although most studies reporting these complications involve the use of nonresorbable nasal packing only.[5][49]

Select antibiotics that have activity against typical sinusitis pathogens and Staphylococcus aureus.[5] Appropriate antibiotics include amoxicillin/clavulanate or cefuroxime. Consider sulfamethoxazole/trimethoprim or a macrolide in the case of allergy to penicillin or cephalosporins. 

Although there is little evidence of protective benefit from toxic shock syndrome by application of topical antibiotic ointment (e.g., mupirocin), its use to lubricate packing and reduce trauma is reasonable and commonplace.[5]

Primary options

amoxicillin/clavulanate: children <3 months of age and <40 kg body weight: 30 mg/kg/day orally given in 2 divided doses for 5-7 days; children ≥3 months of age and <40 kg body weight: 25-45 mg/kg/day orally given in 2 divided doses or 20-40 mg/kg/day orally given in 3 divided doses for 5-7 days; children ≥3 months of age and ≥40 kg body weight and adults: 500-875 mg orally twice daily or 250-500 mg orally three times daily for 5-7 days

More

or

cefuroxime axetil: children: 20-30 mg/kg/day orally given in 2 divided doses for 5-7 days, maximum 1000 mg/day; adults: 250-500 mg orally twice daily for 5-7 days

-- AND --

mupirocin topical: (2% ointment) children and adults: apply generously to saturate nasal packing before placement

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-10 mg/kg/day orally given in 2-4 divided doses for 5-7 days; adults: 160 mg orally twice daily for 5-7 days

More

or

clarithromycin: children ≥6 months of age: 15 mg/kg/day orally given in 2 divided doses for 5-7 days; adults: 250-500 mg orally twice daily for 5-7 days

or

azithromycin: children: 10-12 mg/kg (maximum 500 mg/dose) orally once daily on day 1, followed by 5-6 mg/kg (maximum 250 mg/dose) once daily for 4 days; adults: 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

-- AND --

mupirocin topical: (2% ointment) children and adults: apply generously to saturate nasal packing before placement

Consider – analgesia

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

Prescribe analgesia, as appropriate, for discomfort.

Acetaminophen may provide adequate relief, and has been shown to be effective after ENT procedures including sinus surgery.[51]​ Avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

If pain is not controlled with acetaminophen, treatment may be escalated to a suitable opioid (e.g., acetaminophen/hydrocodone).

Use opioids with caution in children, older patients, and patients who are in shock. Opioids are associated with a risk of addiction, abuse, and misuse which can lead to overdose and potentially death. Risk should be assessed before prescribing, and regularly reassessed during treatment. Opioids may cause life-threatening respiratory depression, especially during treatment initiation or dose titration. Avoid concomitant use of other central nervous system depressants, including alcohol.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

hydrocodone/acetaminophen: children ≥2 years of age: consult specialist for guidance on dose; adults: 2.5 to 10 mg orally every 4-6 hours when required

More

Consider – antiemetic

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

antiemetic

Treatment recommended for SOME patients in selected patient group

Give an antiemetic (e.g., ondansetron) for nausea that may be caused by swallowed blood.

Primary options

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required

Consider – resuscitation and supportive care

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

resuscitation and supportive care

Treatment recommended for SOME patients in selected patient group

Prompt assessment of bleeding severity will assist in directing the patient to the proper clinical site for management. Few studies address the most appropriate setting for care of nosebleeds.[5]

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of hemodynamic compromise. Such patients need urgent resuscitation in the hospital.[5] Patients may be more prone to hemodynamic compromise if: 1) there is severe bleeding, indicated by a large volume of blood, prolonged bleeding, bleeding from both sides of the nose, or bleeding from the mouth. Severe bleeding may be more likely with a history of hospitalization for nosebleed, prior blood transfusion for nosebleed, or more than 3 recent nosebleeds; 2) the patient is older; or 3) the patient is ill or frail. Comorbidities that may impede the patient's response to a bleed include hypertension, cardiopulmonary disease, anemia, bleeding disorders, and liver or kidney disease.[5]

Oxygen supplementation, intravenous access, urgent complete blood count, platelets, clotting studies, and blood type for transfusion are required, along with the maintenance of airway, breathing, and circulation (ABC).

Consider – treatment of underlying cause

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

Underlying causes may become apparent at this stage.

Coagulation disorders require management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Treat local causes (e.g., foreign body, polyp, ulceration to the skin around the nose) accordingly.

Provide a post-treatment nosebleed instruction sheet.

3rd line – posterior packing

Back
ACUTE
|
active epistaxis: bleeding site visible
3rd line – 

posterior packing

Perform posterior packing in an emergency department or hospital setting. Care of patients requiring this level of packing should involve an otolaryngology attending.[5]

Anterior-posterior nasal packing is indicated: 1) for known posterior bleeding; 2) in case of failure of a properly placed anterior pack to control hemorrhage.

Use anterior packing to reinforce posterior packing; the pressure at the posterior choanal area prevents anterior blood flow.

A variety of posterior pack options exist, although the methods described below provide both effectiveness and ease of placement. These are: 1) the double-balloon epistaxis device; 2) the traditional gauze anterior pack with the Foley urinary catheter placed posteriorly.

[Figure caption and citation for the preceding image starts]: Anterior-posterior traditional Foley catheter-gauze packFrom the collection of David A. Randall, Springfield Ear Nose Throat and Facial Plastic Surgery, MO [Citation ends].com.bmj.content.model.Caption@158d8aff

There has been concern about posterior packs causing hypoxia, and the need for intensive cardiorespiratory monitoring while the packs remain in place.[5] Some authors recommend observation of patients in the intensive care unit while posterior packing is in place, while others feel that this is appropriate specifically for older people and patients with comorbidities.

Remove packing after 2 to 3 days to allow healing of the original and possibly secondary (from excoriation of packing placement) bleeding sites.[5]

Consider – antibiotic therapy

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Although controversial, consider oral antibiotics on an individual basis while packing remains in place.[5] Infection risks from nasal packing include local infection, bacteremia, and (rarely) toxic shock syndrome, although most studies reporting these complications involve the use of nonresorbable nasal packing only.[5][49]

Select antibiotics that have activity against typical sinusitis pathogens and Staphylococcus aureus.[5] Appropriate antibiotics include amoxicillin/clavulanate or cefuroxime. Consider sulfamethoxazole/trimethoprim or a macrolide (e.g., clarithromycin, azithromycin) in the case of allergy to penicillin or cephalosporins. 

Although there is little evidence of protective benefit from toxic shock syndrome by application of topical antibiotic ointment (e.g., mupirocin), its use to lubricate packing and reduce trauma is reasonable and commonplace.[5]

Primary options

amoxicillin/clavulanate: children <3 months of age and <40 kg body weight: 30 mg/kg/day orally given in 2 divided doses for 5-7 days; children ≥3 months of age and <40 kg body weight: 25-45 mg/kg/day orally given in 2 divided doses or 20-40 mg/kg/day orally given in 3 divided doses for 5-7 days; children ≥3 months of age and ≥40 kg body weight and adults: 500-875 mg orally twice daily or 250-500 mg orally three times daily for 5-7 days

More

or

cefuroxime axetil: children: 20-30 mg/kg/day orally given in 2 divided doses for 5-7 days, maximum 1000 mg/day; adults: 250-500 mg orally twice daily for 5-7 days

-- AND --

mupirocin topical: (2% ointment) children and adults: apply generously to saturate nasal packing before placement

Secondary options

sulfamethoxazole/trimethoprim: children ≥2 months of age: 8-10 mg/kg/day orally given in 2-4 divided doses for 5-7 days; adults: 160 mg orally twice daily for 5-7 days

More

or

clarithromycin: children ≥6 months of age: 15 mg/kg/day orally given in 2 divided doses for 5-7 days; adults: 250-500 mg orally twice daily for 5-7 days

or

azithromycin: children: 10-12 mg/kg (maximum 500 mg/dose) orally once daily on day 1, followed by 5-6 mg/kg (maximum 250 mg/dose) once daily for 4 days; adults: 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

-- AND --

mupirocin topical: (2% ointment) children and adults: apply generously to saturate nasal packing before placement

Consider – analgesia

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

Prescribe analgesia, as appropriate, for discomfort.

Acetaminophen may provide adequate relief, and has been shown to be effective after ENT procedures including sinus surgery.[51]​ Avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

If pain is not controlled with acetaminophen, treatment may be escalated to a suitable opioid (e.g., acetaminophen/hydrocodone). Greater patient discomfort with posterior nasal packing warrants consideration of an intravenous opioid (e.g., morphine) prior to packing.

Use opioids with caution in children, older patients, and patients who are in shock. Opioids are associated with a risk of addiction, abuse, and misuse which can lead to overdose and potentially death. Risk should be assessed before prescribing, and regularly reassessed during treatment. Opioids may cause life-threatening respiratory depression, especially during treatment initiation or dose titration. Avoid concomitant use of other central nervous system depressants, including alcohol.

Lidocaine with epinephrine (adrenaline) may be infiltrated in the vicinity of a bleeding site. There is hemostatic benefit from the epinephrine and possibly from hydrostatic tissue pressure of the infiltrated volume of drug. This method is a requirement before electrocautery is undertaken but may be used with other treatments.

Posterior analgesia and vasoconstriction may be facilitated by local anesthetic infiltration into the greater palatine foramen. This block technique should be used with caution and only in experienced hands because it is painful and has the rare potential for blindness. This is rarely used.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

hydrocodone/acetaminophen: children ≥2 years of age: consult specialist for guidance on dose; adults: 2.5 to 10 mg orally every 4-6 hours when required

More

OR

morphine sulfate: children: consult specialist for guidance on dose; adults: 2.5-10 mg intravenously every 2-6 hours when required, adjust dose according to response

Consider – antiemetic

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

antiemetic

Treatment recommended for SOME patients in selected patient group

Greater patient discomfort with posterior nasal packing warrants consideration of an antiemetic prior to packing. Pretreatment with an antiemetic avoids nausea and emesis. Ondansetron avoids sedation associated with drugs such as promethazine.

Primary options

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required

Consider – resuscitation and supportive care

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

resuscitation and supportive care

Treatment recommended for SOME patients in selected patient group

Prompt assessment of bleeding severity will assist in directing the patient to the proper clinical site for management. Few studies address the most appropriate setting for care of nosebleeds.[5]

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of hemodynamic compromise. Such patients need urgent resuscitation in the hospital.[5] Patients may be more prone to hemodynamic compromise if: 1) there is severe bleeding, indicated by a large volume of blood, prolonged bleeding, bleeding from both sides of the nose, or bleeding from the mouth. Severe bleeding may be more likely with a history of hospitalization for nosebleed, prior blood transfusion for nosebleed, or more than 3 recent nosebleeds; 2) the patient is older; or 3) the patient is ill or frail. Comorbidities that may impede the patient's response to a bleed include hypertension, cardiopulmonary disease, anemia, bleeding disorders, and liver or kidney disease.[5]

Oxygen supplementation, intravenous access, urgent complete blood count, platelets, clotting studies, and blood type for transfusion are required, along with the maintenance of airway, breathing, and circulation (ABC).

Consider – treatment of underlying cause

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

Coagulation disorders require management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Treat local causes (e.g., neoplasm, foreign body, polyp, ulceration to the skin around the nose) accordingly.

Provide a post-treatment nosebleed instruction sheet.

4th line – endoscopic management or angiography and embolization

Back
ACUTE
|
active epistaxis: bleeding site visible
4th line – 

endoscopic management or angiography and embolization

Nasal packing and cautery will successfully treat most nosebleeds. Otolaryngology referral is indicated when these techniques fail. Various procedures may be used to manage persistent bleeding. The choice will depend on availability of appropriate resources and expertise.[5][52][53][54][55][56][57][58]

The advent of rigid nasal endoscopy has greatly improved visualization and access to the nose. Endoscopic identification and guided electrocautery to posterior bleeding sites have become more common and an effective alternative to nasal packing.[5] Suction cautery under direct visualization may control some nosebleeds located posteriorly. Similarly, surgical dissection and surgical clip ligation of the sphenopalatine artery (SPA) may be accomplished under direct endoscopic vision.[54][55] SPA ligation is the mainstay of treatment when conservative management of posterior epistaxis has failed.[60] It is usually performed under a general anesthetic but can be accomplished under sedation with local anesthetic.

Angiography and embolization with interventional radiology offers another means of interrupting the arterial supply, avoiding the need for surgery. If contemplating this technique, try it before transantral ligation because the latter often occludes access vessels necessary for successful embolization.[57][58][61]

Endovascular embolization is appropriate for treating posterior epistaxis and involves embolization of the bilateral sphenopalatine/distal internal maxillary arteries. Sometimes, the facial arteries require embolization if there are anastomoses with the SPA via the infraorbital artery and alar and septal branches from the anterior nasal compartment.[5]

An advantage of endoscopic arterial ligation is that concurrent endoscopic SPA and endoscopic anterior ethmoidal artery ligation can be performed; however, the need for general anesthesia is a disadvantage.[5]

Advantages of embolization include the ability to perform the procedure under sedation, avoid trauma to the nasal mucosa, and leave packs in place, but there is some risk of occlusion of adjacent vessels and the potential for cerebrovascular accident.[5] A sequential approach of transnasal endoscopic SPA ligation (TESPAL) followed by endovascular embolization for epistaxis that does not respond to packing has been suggested.[5][59]

Obtain detailed prior angiography (including internal and external carotid arteries) because blindness and stroke are serious complications that, although rare, occur more frequently than in patients undergoing surgical arterial ligation. Endovascular embolization of the anterior and/or posterior ethmoid arteries is contraindicated, because of the risk of blindness.[5]

Consider – analgesia

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

Prescribe analgesia, as appropriate, for discomfort.

Acetaminophen may provide adequate relief, and has been shown to be effective after ENT procedures including sinus surgery.[51]​ Avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

If pain is not controlled with acetaminophen, treatment may be escalated to a suitable opioid (e.g., acetaminophen/hydrocodone).

Use opioids with caution in children, older patients, and patients who are in shock. Opioids are associated with a risk of addiction, abuse, and misuse which can lead to overdose and potentially death. Risk should be assessed before prescribing, and regularly reassessed during treatment. Opioids may cause life-threatening respiratory depression, especially during treatment initiation or dose titration. Avoid concomitant use of other central nervous system depressants, including alcohol.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

hydrocodone/acetaminophen: children ≥2 years of age: consult specialist for guidance on dose; adults: 2.5 to 10 mg orally every 4-6 hours when required

More

Consider – antiemetic

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

antiemetic

Treatment recommended for SOME patients in selected patient group

The anesthetist may prescribe an antiemetic (e.g., ondansetron) as needed for nausea postoperatively.

Primary options

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required

Consider – resuscitation and supportive care

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

resuscitation and supportive care

Treatment recommended for SOME patients in selected patient group

Prompt assessment of bleeding severity will assist in directing the patient to the proper clinical site for management. Few studies address the most appropriate setting for care of nosebleeds.[5]

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of hemodynamic compromise. Such patients need urgent resuscitation in the hospital.[5] Patients may be more prone to hemodynamic compromise if: 1) there is severe bleeding, indicated by a large volume of blood, prolonged bleeding, bleeding from both sides of the nose, or bleeding from the mouth. Severe bleeding may be more likely with a history of hospitalization for nosebleed, prior blood transfusion for nosebleed, or more than 3 recent nosebleeds; 2) the patient is older; or 3) the patient is ill or frail. Comorbidities that may impede the patient's response to a bleed include hypertension, cardiopulmonary disease, anemia, bleeding disorders, and liver or kidney disease.[5]

Oxygen supplementation, intravenous access, urgent complete blood count, platelets, clotting studies, and blood type for transfusion are required, along with the maintenance of airway, breathing, and circulation (ABC).

Consider – treatment of underlying cause

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

Coagulation disorders require management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Treat local causes (e.g., foreign body, polyp, ulceration to the skin around the nose) accordingly.

Provide a post-treatment nosebleed instruction sheet.

5th line – open surgical ligation

Back
ACUTE
|
active epistaxis: bleeding site visible
5th line – 

open surgical ligation

Posterior epistaxis may be amenable to endoscopically guided electrocautery (usually monopolar suction cautery). Similarly, surgical dissection and surgical clip ligation of the sphenopalatine artery may be accomplished under direct endoscopic vision. These procedures normally require general anesthetic or at least conscious sedation in the operating room. Packing is therefore the more amenable primary option.

Angiography and embolization offers another means of interrupting the arterial supply. This avoids the need for surgery but involves some risk of occlusion of adjacent vessels and the potential for cerebrovascular accident. If contemplated, this technique should be tried before transantral ligation because this surgery often occludes access vessels necessary for successful embolization.

Consider – analgesia

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

Prescribe analgesia, as appropriate, for discomfort.

Acetaminophen may provide adequate relief, and has been shown to be effective after ENT procedures including sinus surgery.[51]​ Avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs).

If pain is not controlled with acetaminophen, treatment may be escalated to a suitable opioid (e.g., acetaminophen/hydrocodone).

Use opioids with caution in children, older patients, and patients who are in shock. Opioids are associated with a risk of addiction, abuse, and misuse which can lead to overdose and potentially death. Risk should be assessed before prescribing, and regularly reassessed during treatment. Opioids may cause life-threatening respiratory depression, especially during treatment initiation or dose titration. Avoid concomitant use of other central nervous system depressants, including alcohol.

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Secondary options

hydrocodone/acetaminophen: children ≥2 years of age: consult specialist for guidance on dose; adults: 2.5 to 10 mg orally every 4-6 hours when required

More

Consider – antiemetic

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

antiemetic

Treatment recommended for SOME patients in selected patient group

The anesthetist may prescribe an antiemetic (e.g., ondansetron) as needed for nausea postoperatively.

Primary options

ondansetron: children: consult specialist for guidance on dose; adults: 4-8 mg intravenously every 4-8 hours when required

Consider – resuscitation and supportive care

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

resuscitation and supportive care

Treatment recommended for SOME patients in selected patient group

Prompt assessment of bleeding severity will assist in directing the patient to the proper clinical site for management. Few studies address the most appropriate setting for care of nosebleeds.[5]

Generally, resuscitation is not required in most people presenting with epistaxis, but is required in the rare instance of hemodynamic compromise. Such patients need urgent resuscitation in the hospital.[5] Patients may be more prone to hemodynamic compromise if: 1) there is severe bleeding, indicated by a large volume of blood, prolonged bleeding, bleeding from both sides of the nose, or bleeding from the mouth. Severe bleeding may be more likely with a history of hospitalization for nosebleed, prior blood transfusion for nosebleed, or more than 3 recent nosebleeds; 2) the patient is older; or 3) the patient is ill or frail. Comorbidities that may impede the patient's response to a bleed include hypertension, cardiopulmonary disease, anemia, bleeding disorders, and liver or kidney disease.[5]

Oxygen supplementation, intravenous access, urgent complete blood count, platelets, clotting studies, and blood type for transfusion are required, along with the maintenance of airway, breathing, and circulation (ABC).

Consider – treatment of underlying cause

Back
ACUTE
|
active epistaxis: bleeding site visible
Consider – 

treatment of underlying cause

Treatment recommended for SOME patients in selected patient group

Coagulation disorders require management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Treat local causes (e.g., neoplasm, foreign body, polyp, ulceration to the skin around the nose) accordingly.

Provide a post-treatment nosebleed instruction sheet.

ONGOING

quiescent but recurrent epistaxis

1st line – treatment of underlying cause

Back
ONGOING
|
quiescent but recurrent epistaxis
1st line – 

treatment of underlying cause

The patient may present with recurrent epistaxis that is not currently active.

Recurrent episodes may also occur in people with coagulation disorders, neoplasms, and familial hereditary hemorrhagic telangiectasia.

On occasion, the nasal septum is re-lined with a skin graft (septal dermoplasty).[22][23][66]

Coagulation disorders require management depending on the underlying cause.

Patients with hereditary hemorrhagic telangiectasia have a lifelong proclivity for bleeding from dilated, fragile mucosal vessels. Periodic prophylactic silver nitrate, electrocautery, or laser treatment may ablate vessels. Resurfacing of the septum (septal dermoplasty) may be an option.[22][23][66]

Neoplasms and trauma must be addressed according to the particular nature of the patient's disease. Preoperative embolization reduces blood loss in some cases: for example, juvenile nasal angiofibroma.[12]

Coagulopathy requires management depending on the underlying cause and may need to be corrected with transfusion of platelets, or clotting factors.

Consider – silver nitrate cautery

Back
ONGOING
|
quiescent but recurrent epistaxis
Consider – 

silver nitrate cautery

Treatment recommended for SOME patients in selected patient group

This is a common scenario in children.

Determine which side has the worst bleeding, as this would be the side selected for cautery. It is important to avoid cautery on both sides of the septum at the same visit.[46]​ This deprives the septal cartilage of its blood supply (from the mucosal covering) and may result in septal perforation if done bilaterally. Defer similar treatment of the other side for about 4 weeks until the initial cautery site has healed.

Younger children may not tolerate simple office cautery even with good topical anesthesia and thus require brief general anesthetic.

Silver nitrate cautery has been compared with antiseptic creams in children with recurrent epistaxis.[63][64] One Cochrane review of interventions in children is inconclusive, but does suggest that if silver nitrate cautery is used, a 75% preparation may be more effective and less painful than 95%.[63] Petroleum jelly has been compared with no treatment.[63] The evidence for antiseptic creams and petroleum jelly is still limited and high quality randomized controlled trials with longer follow-up periods are required.[63][64][67] A late double-blind study suggests that silver nitrate cautery plus antiseptic cream confers greater benefit than antiseptic cream alone.[65]

Consider – endoscopic management or angiography and embolization or open surgery

Back
ONGOING
|
quiescent but recurrent epistaxis
Consider – 

endoscopic management or angiography and embolization or open surgery

Treatment recommended for SOME patients in selected patient group

An ear, nose, and throat specialist assesses which of the options would best balance the risks and benefits for each individual patient.

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