Epistaxis in the ED: When it Bleeds, it pours

-Case-

A 67-year-old man with a history of HTN and daily aspirin use presents with a persistent nosebleed for the last hour. He’s tried applying pressure and using tons of tissues but nothing has helped. He’s hemodynamically stable, but actively bleeding from the right naris.

-Evaluation-

Epistaxis is fairly common in the ED and thankfully, most cases are benign. It’s helpful to divide nosebleeds into anterior vs posterior bleeds.

  • Anterior epistaxis (~90% of cases): arises from Kiesselbach’s plexus in the anterior nasal septum
  • Posterior epistaxis: often more severe, arising from deeper branches like the sphenopalatine artery

Risk factors include:

  • Dry air
  • Digital trauma (nose picking)
  • Anticoagulant/antiplatelet use
  • HTN
  • Coagulopathies

-Initial Approach-

  1. Ensure airway, breathing, circulation (ABCs) are intact.
  2. Have the patient sit up and lean forward to avoid blood aspiration.
  3. Apply firm pressure to the soft part of the nose (not the bony bridge) for 15 continuous minutes.
  4. Consider topical vasoconstrictors (oxymetazoline or lidocaine with epinephrine) if bleeding persists.

Next steps if still bleeding:

  • Visualization: Use suction and a nasal speculum to identify the bleeding source.
  • Cauterize the site with silver nitrate if clearly visualized (avoid bilateral cautery to prevent septal perforation).
  • Packing: If cautery fails or source not visualized:
    • Use anterior nasal packing for anterior bleeds.
    • Use posterior nasal balloon devices or consult ENT for posterior bleeds.

Posterior epistaxis is harder to control and often needs ENT involvement. These patients frequently require admission for airway monitoring and packing management.

Don’t forget:

  • Labs: CBC, type and screen, INR/PTT if high-risk or recurrent bleeds.
  • Blood pressure control is key in refractory bleeding.
  • Antibiotics: controversial, but many recommend for packed noses to prevent TSS or sinusitis (e.g., amoxicillin-clavulanate).

-Fast Facts-

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  • Most nosebleeds are anterior and can be treated with pressure, vasoconstrictors, or cautery.
  • Bilateral cautery should be avoided due to risk of septal necrosis.
  • Posterior bleeds are less common but more serious.
  • Always reassess hemodynamics and airway, especially in persistent bleeds.

For stubborn bleeds, remember the mnemonic “COPS“:
Compression
Oxymetazoline
Packing
Silver nitrate

Want to learn more? Listen to our in-depth podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

References:

  1. Pallin DJ, Chng Y-M, McKay MP, et al. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46(1):77-81.
  2. Ando M, Asai T, Ando Y, et al. Effectiveness of silver nitrate cautery for anterior epistaxis: A prospective study. Am J Emerg Med. 2020;38(12):2562-2565.
  3. Villwock JA, Jones K. Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngol Head Neck Surg. 2013;139(12):1279-1284.
  4. Kilty SJ, Al-Hajry M, Salama A, et al. Prospective randomized controlled trial of antibiotic prophylaxis in nasal packing for epistaxis. Laryngoscope. 2008;118(4):664-667.
  5. Tunkel DE, Anne S. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020;162(1_suppl):S1-S38.
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