Anterior epistaxis | CMAJ

Direct compression of the nasal alae (lower third of the nose) with the head tilted forward will stop many bleeds

Epistaxis is the primary reason for 1 in 313 ED visits.1 Correct application of pressure is the only intervention required in about 20% of cases.2

Topical medications and cautery can control anterior nasal bleeding that cannot be resolved with direct compression

Topical medications (such as oxymetazoline, tranexamic acid or lidocaine with epinephrine on a cotton pad) can help control bleeding.3 Once a source of bleeding is visualized, it can be cauterized using chemical (silver nitrate) or electrical cautery. Bilateral cauterization of the septum can cause septal perforation and should be avoided.

Resorbable packing or tamponade may be necessary in about one-fifth of cases

Around 20% of epistaxis cases that present to the emergency department require nasal packing.1 Resorbable packing (carboxymethylcellulose, gelatin sponge, or gelatin and thrombin slurry) does not require removal and is best suited for patients with bleeding disorders.4 Patients with persistent bleeding may require tamponade with a nonresorbable pack.

Anticoagulation is associated with morbidity from epistaxis

Patients taking either anticoagulant or antiplatelet therapy are at increased risk of severe epistaxis (odds ratio [OR] 1.8) and hospital admission (OR 2.2) compared with patients not on these medications.5 In patients with recurrent or uncontrolled epistaxis secondary to coagulopathy, reversal or alternate strategies for anticoagulation should be considered, where possible. Direct oral anticoagulants may have a better safety profile than warfarin or low-molecular-weight heparin.5

Postepistaxis care is important to avoid rebleeding

Using moisturizers and lubricants (i.e., gel or saline), and air humidification, especially for patients who use continuous positive airway pressure, can protect the mucosa and prevent rebleeds.4 Avoiding nose picking, heavy lifting and smoking can reduce recurrent episodes.4

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