Which procedures and medications are used in the treatment of epistaxis (nosebleed), and how should epistaxis be managed in light of the coronavirus disease 2019 (COVID-19) pandemic?

Updated: May 08, 2020
  • Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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When medical attention is needed for epistaxis, it is usually because of the problem is either recurrent or severe. Treatment depends on the clinical picture, the experience of the treating physician, and the availability of ancillary services.

In most patients with epistaxis, the bleeding responds to cauterization, nasal packing, or both. For those who have recurrent or severe bleeding for which medical therapy has failed, various surgical options are available. After surgery or embolization, patients should be closely observed for any complications or signs of rebleeding.

Medical approaches to the treatment of epistaxis may include the following:

  • Adequate pain control in patients with nasal packing, especially in those with posterior packing (However, the need of adequate pain control has to be balanced with the concern over hypoventilation in the patient with posterior pack.)

  • Oral and topical antibiotics to prevent rhinosinusitis and possibly toxic shock syndrome

  • Avoidance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)

  • Medications to control underlying medical problems (eg, hypertension, vitamin K deficiency) in consultation with other specialists

Also see Anterior Epistaxis Nasal Pack, Posterior Epistaxis Nasal Pack, and Surgery for Pediatric Epistaxis.

Coronavirus disease 2019 (COVID-19)

In May 2020, clinical recommendations out of Italy were published regarding the management of epistaxis during the coronavirus disease 2019 (COVID-19) pandemic. [18]

Personal protection recommendations include the following [18] :

  • Disposable equipment use is strictly recommended
  • FFP3 (Europe) or N99 (United States) masks are preferred, but if FFP3 masks are unavailable, FFP2 or N95 masks, covered by a surgical mask, can be used
  • It is strongly recommended that health-care personnel employ cap and shoe covers, goggles, gowns, and double nitrile gloves

Clinical assessment recommendations include the following [18] :

  • Nosebleed risk factors (ie, blood pressure, coagulation factors, ongoing therapies with antithrombotic or anticoagulant drugs) should be controlled
  • The patient should be checked for fever, respiratory symptoms, and contacts at risk for COVID-19
  • Investigate sudden loss of smell and/or taste
  • If allowed, dress patients with a surgical mask
  • Promptly assess the nosebleed’s severity
  • It is recommended that noninvasive intervention (bidigital compression, administration of antifibrinolytic agents) be employed

Room setting recommendations include the following [18] :

  • If conventional operating rooms are unavailable, employ well-demarcated areas within the emergency department complex
  • The patient should be treated by a reduced and experienced clinical staff, including a surgeon and a scrub nurse, with proper personal protective equipment (PPE)

Treatment recommendations include the following [18] :

  • Avoid unnecessary interventions
  • If noninvasive procedures fail, nasal packing or cautery should be performed
  • Resorbable packing, if available, is recommended
  • If sphenopalatine artery ligation is needed for posterior epistaxis, the procedure should be postponed until COVID-19 testing has been performed
  • Avoid using local anesthetic atomized sprays, employing soaked pledgets instead
  • During the procedure, a suction system, within a closed system and employing a viral filter, should be used

Postprocedure recommendations include the following [18] :

  • To reduce recurrence risk and optimize outcomes, the patient should receive postprocedural instructions on packing removal or antibiotic prophylaxis
  • Carefully execute gowning and degowning procedures
  • Standard PPE should be employed by personnel engaged in the decontamination of surgical equipment

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