November 2024
A 25-year-old woman presents to urgent care with a chief complaint of epistaxis in her right nostril that started 30 minutes earlier spontaneously at home. She reports that the bleeding is significant, needing to apply pressure multiple times to stop it. Bidigital compression helps, but once she releases the pressure, the bleeding resumes. The patient says that she has had 1 or 2 similar episodes in the past few months, but those resolved with compression. She recovered from a mild cold 2 weeks ago; she denies current fever, cough, or sore throat.
She reports mild dizziness and anxiety, but no shortness of breath, chest pain, or syncope. Her physical examination is normal. Her history is unremarkable: no chronic illnesses, no drug use or allergies, no recent medication additions or changes, and no family history of bleeding disorders, hypertension, or cardiovascular disease.
Which of the following is the most appropriate initial management for a patient presenting with anterior epistaxis, like the 25-year-old woman in this case?
- Immediate nasal packing with gauze
- Application of pressure to the anterior nose for 10 to 15 minutes
- Referral to otolaryngology for nasal cauterization
- Begin intravenous access for coagulation factor replacement
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Answer: b. Application of pressure to the anterior nose for 10 to 15 minutes.
Conclusion and follow-up: Most anterior epistaxis cases can be controlled with the application of pressure to the distal part of the nose for 10 to 15 minutes, followed by observation for 30 minutes to rule out rebleeding. The patient was asked to lean forward in a chair to prevent swallowing of blood. This conservative approach was effective. No additional testing was needed, but if her bleeding had persisted, a vasoconstrictor spray such as oxymetazoline would have been the next treatment option, followed by nasal packing or cauterization. Referral to otolaryngology would be appropriate if her history was indicative of recurrent or refractory epistaxis. Coagulation factor replacement was not indicated, as she did not have a history of a bleeding disorder or severe blood loss.
Most cases of epistaxis in young adults are benign, especially if associated with recent nasal irritation. This patient was discharged with nasal care instructions that included avoiding nose picking or blowing her nose forcefully, using a saline nasal gel or humidifier to keep her nasal passages moist, and following up with an otolaryngologist if further episodes occur.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
