Epistaxis medical therapy

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Epistaxis Microchapters


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief:Amir Behzad Bagheri, M.D. José Eduardo Riceto Loyola Junior, M.D.[2]


Most of the time no action is needed to stop epistaxis. In active bleeding, nasal compression is the first line strategy to stop bleeding. If bleeding continues there are other options such as cautery and vasoconstrictive agents such as oxymetazoline or phenylephrine to control bleeding.

Medical Therapy

If nasal bleeding is active and nasal compression cannot stop the bleeding, there are the following medical options:[1] [2] [3] [4] [5]

  • General management of patients is important. Stabilizing the patient and treating the specific cause is the basis of management.
  • At first airway, breathing and circulation should be evaluated.

An algorithm for the management of epistaxis is depicted below:[6]

Treatment by a primary care physician or emergency physician
Compression of the nostrils
❑ Ice application to the neck area
❑ Upright sitting position
❑ Blood to be spat out
❑ Take blood pressure, lower if appropriate
Patient hemodinamically stable, bleeding stops
Patient hemodinamically unstable
Patient hemodinamically stable, bleeding persists
❑ 30min observation,
Antiseptic nasal cream
Emergency transfer to ENT department
Volume replacement
Bleeding stops:
❑ Discharge patient home
❑ Prevent recurrence;
❑ Nasal mucosal care
❑ No nose-blowing for 7-10 days
Bleeding resumes
Emergency referral to otorhinolaryngologist
Anterior rhinoscopy
Endoscopy if required
Source of bleeding visible, anterior
Source of bleeding not visible and/or posterior
Bleeding stops:
❑ Discharge patient home
❑ Prevent recurrence;
❑ Nasal mucosal care
❑ No nose-blowing for 7-10 days
Eletrocoagulation or silver nitrate cautery;
Hemostatic gauze if required
Bleeding persists:
Nasal packing
Nasal packing
Treatment of epistaxis in the ENT department
Bleeding stops
Bleeding persists, patient fit for surgery
Bleeding persists, patient not fit for surgery
Remove packing after 48h, antibiotics if needed
Surgical treatment, usually endoscopic sphenopalatine ligation
If bleeding persists, embolization
If bleeding persists:
Patient fit for surgery - surgery
Patient not fit for surgery - embolization

Medical Therapy:


  1. Tunkel, David E.; Anne, Samantha; Payne, Spencer C.; Ishman, Stacey L.; Rosenfeld, Richard M.; Abramson, Peter J.; Alikhaani, Jacqueline D.; Benoit, Margo McKenna; Bercovitz, Rachel S.; Brown, Michael D.; Chernobilsky, Boris; Feldstein, David A.; Hackell, Jesse M.; Holbrook, Eric H.; Holdsworth, Sarah M.; Lin, Kenneth W.; Lind, Meredith Merz; Poetker, David M.; Riley, Charles A.; Schneider, John S.; Seidman, Michael D.; Vadlamudi, Venu; Valdez, Tulio A.; Nnacheta, Lorraine C.; Monjur, Taskin M. (2020). "Clinical Practice Guideline: Nosebleed (Epistaxis)". Otolaryngology–Head and Neck Surgery. 162 (1_suppl): S1–S38. doi:10.1177/0194599819890327. ISSN 0194-5998.
  2. Krempl, Greg A.; Noorily, Allen D. (2016). "Use of Oxymetazoline in the Management of Epistaxis". Annals of Otology, Rhinology & Laryngology. 104 (9): 704–706. doi:10.1177/000348949510400906. ISSN 0003-4894.
  3. Montastruc, François; Montastruc, Guillaume; Taudou, Marie-Josée; Olivier-Abbal, Pascale; Montastruc, Jean-Louis; Bondon-Guitton, Emmanuelle (2014). "Acute Coronary Syndrome After Nasal Spray of Oxymetazoline". Chest. 146 (6): e214–e215. doi:10.1378/chest.14-1873. ISSN 0012-3692.
  4. Krulewitz, Neil Alexander; Fix, Megan Leigh (2019). "Epistaxis". Emergency Medicine Clinics of North America. 37 (1): 29–39. doi:10.1016/j.emc.2018.09.005. ISSN 0733-8627.
  5. Douglas, Richard; Wormald, Peter-John (2007). "Update on epistaxis". Current Opinion in Otolaryngology & Head and Neck Surgery. 15 (3): 180–183. doi:10.1097/MOO.0b013e32814b06ed. ISSN 1068-9508.
  6. Beck R, Sorge M, Schneider A, Dietz A (2018). "Current Approaches to Epistaxis Treatment in Primary and Secondary Care". Dtsch Arztebl Int. 115 (1–02): 12–22. doi:10.3238/arztebl.2018.0012. PMC 5778404. PMID 29345234.

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