The association between hypertension and epistaxis is complicated. Hypertension does not cause epistaxis but may prolong it. Therapy focuses on control of the hemorrhage rather than reduction of the blood pressure. Analgesia and mild sedation are preferable to antihypertensive therapy.

For patients with severe or recurrent hemorrhage or underlying medical conditions, a complete blood count should be performed, as well as a type and screen. In selected patients, such as those taking warfarin or with hepatic or renal dysfunction, coagulation studies are warranted.

No matter the choice of treatment, the patient should be observed for at least 1 hour after control. Encourage the patient to walk or perform other activities that he or she will need to resume when returning home.

Follow-up instructions include stopping aspirin and NSAIDs for a few days. In the patient treated by cautery, Vaseline or a similar moisturizing agent should be applied liberally in the nose three times a day for 7-10 days to promote healing of friable mucosa and superficial vessels. For the patient with a nasal pack, prescribe analgesics for comfort and arrange ENT follow-up in 3 days.

The role of prophylactic systemic antibiotics in patients who have nasal packs is not well established with wide variations in practice. Although studies to date do not directly address the issue, having been done primarily in patients with postsurgical packing, most sources recommend TMP/SMX, cephalexin, or amoxicillin/clavulanic acid to prevent sinusitis and toxic shock syndrome.

All patients requiring a posterior pack should be admitted because of the risk of airway obstruction and subsequent hypoxemia and dysrhythmias. Supplemental oxygen is administered once the pack is placed. Patients who have sustained significant blood loss or who have abnormal vital signs or concerning comorbidities, including coagulopathies, should be hospitalized. Finally, those with refractory epistaxis despite the above measures are admitted for vessel ligation or selective arterial embolization.

In the past several years, there has been a significant expansion in the number of options available to treat epistaxis. Traditional strategies such as nasal packs have been supplemented by the modern technology of hemostatic agents producing less patient discomfort, improved efficacy, fewer complications, and reduced requirement for emergent ENT consultation.

Contributors

Dr. Gilman is an assistant professor in the division of emergency medicine at Medical University of South Carolina, Charleston. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.