Epistaxis Management in a 60-Year-Old Hypertensive Female (BP 160/100 mmHg)

Step 1 - Initial Assessment (Do This Immediately)

• Assess the airway - ensure she can breathe and is not aspirating blood
• Sit her upright, leaning slightly forward (prevents blood from flowing down the throat and being swallowed/aspirated)
• Pinch her nose and let her spit blood into a bowl - do NOT ask her to tilt the head back
• Establish IV access
• Order baseline labs: CBC, PT/INR, aPTT (check for coagulopathy); also a renal panel given HTN history
• Check medication history - is she on aspirin, warfarin, clopidogrel, or NSAIDs?

Note: An elevated BP upon presentation is very common in epistaxis patients, and studies have NOT established a direct causal link between hypertension and epistaxis. However, elevated BP is associated with persistent bleeding. - Rosen's Emergency Medicine, p. 920

Step 2 - First-Line Hemostasis (Do These Together)

A. Direct Pressure

• Ask the patient (or do it yourself) to firmly compress the soft cartilaginous part of the nose (not the bony bridge) for 10 to 15 minutes continuously without releasing
• A nose clip is superior to manual pressure alone

B. Topical Vasoconstrictor Immediately

• Instil 2 sprays of oxymetazoline 0.05% (Afrin/Otrivin) into the affected nostril before applying pressure
• Alternatively, use a cotton pledget soaked in phenylephrine + 4% lidocaine solution - this both decongests and anesthetizes
• These topical vasoconstrictors reduce mucosal blood flow and help achieve hemostasis

Step 3 - Identify the Bleeding Site

• Anterior epistaxis (90% of cases): Bleeding from Kiesselbach's plexus at the anteroinferior nasal septum - visible on inspection, usually unilateral, easier to control
• Posterior epistaxis (10%): More severe, older adults, bleeds from both nostrils or drains into the throat - suspect if anterior measures fail

Step 4 - Escalating Treatment for Active Bleeding

A. Chemical Cautery (if bleeding site is visible)

• Apply a silver nitrate stick to the bleeding point
• Cauterize from the periphery inward, superior to inferior
• Do NOT apply pressure >15 seconds at one spot (risk of septal damage)
• Do NOT cauterize both sides of the septum simultaneously (risk of necrosis)
• Likely to fail during active bleeding - secure hemostasis first, then cauterize

B. Topical Tranexamic Acid (excellent adjunct, especially in this patient)

• Soak a nasal pledget in 500 mg tranexamic acid (IV solution applied topically) and place in the nostril
• Or atomize it into the nasal cavity
• A systematic review found moderate-quality evidence: topical TXA reduces immediate bleeding at 10 minutes and re-bleeding at 7-10 days compared to standard care alone, with no significant adverse events
• Particularly effective in patients on antiplatelet drugs - Rosen's Emergency Medicine, p. 920

C. Topical Thrombogenic Agents

• If cautery is not successful, apply absorbable gelatin sponge (Gelfoam) or absorbable knitted fabric (Surgicel) to the bleeding area

D. Anterior Nasal Packing (if above fail)

• Use a pre-formed pack: Merocel (polyvinyl acetal) nasal tampon or an inflatable Rapid Rhino balloon (coated in procoagulant material)
• Coat the pack in antibiotic ointment, insert along the floor of the nose (horizontally, not upward)
• Inflate Rapid Rhino balloon with air after seating; self-lubricating
• If unilateral pack fails, insert a second pack in the opposite nostril
• Once packed, observe for continued bleeding

Step 5 - If Anterior Packing Fails (Posterior Epistaxis)

• Insert a double balloon catheter (e.g., Epistat device): inflate the posterior balloon first, seat it by pulling anteriorly, then inflate the anterior balloon
• If no commercial device is available, a Foley catheter (12-14 Fr) can be inserted into the nasopharynx, inflated with 5-7 mL water, pulled anteriorly to tamponade the posterior choana
• Admit the patient for monitoring - posterior packing carries risk of hypoxia, vasovagal response, and pressure necrosis
• Urgent ENT consultation is required

Step 6 - Managing the Blood Pressure (BP 160/100)

• Do NOT aggressively lower BP acutely in a setting of active bleeding - the anxiety and pain of the nosebleed itself raise BP, and it usually falls once bleeding is controlled
• Once hemostasis is achieved, reassess BP
• If BP remains elevated:
  • Short-acting oral agent: Amlodipine 5 mg or Labetalol (if no contraindication)
  • Avoid aggressive IV antihypertensives - sudden hypotension can worsen end-organ perfusion in a 60-year-old
• Ensure the patient's chronic antihypertensive medications (if any) are continued
• The goal is controlled BP reduction over hours, not minutes

Step 7 - Refractory Cases (If All Above Fail)

• Endovascular embolization of the sphenopalatine artery - success rate >80%, less invasive, preferred in patients with multiple comorbidities
• Surgical ligation of the sphenopalatine artery (endoscopic approach preferred)
• Anterior/posterior ethmoidal artery ligation for superior bleeding - Rosen's Emergency Medicine, p. 921

Antibiotics?

Summary Algorithm

1. Initial Assessment - stabilize, IV access, labs
2. First-Line Hemostasis - oxymetazoline spray + 15 minutes of firm pinching
3. Check if bleeding stopped - if yes, observe and manage BP; if no, escalate
4. Identify the bleeding source - anterior (90%) vs posterior (10%)
5. Escalating treatment - cautery → tranexamic acid → Gelfoam → anterior nasal packing
6. Check again - if controlled, discharge with follow-up; if not, move to posterior protocol
7. Posterior epistaxis protocol - balloon catheter, admit, ENT consult
8. Refractory cases - embolization or surgical ligation
9. BP management - always addressed after hemostasis, not before