The Hospitalist’s Management of Epistaxis: Evidence-Based Management, From ABCs to Topical TXA and Anticoagulation Tightropes

In this episode of Hospital Medicine Unplugged, we discuss epistaxis—from initial management to preventing recurrence, with evidence-based strategies for hospitalized patients.

We start with stabilization—the priority is always airway, breathing, and circulation. Massive epistaxis can compromise hemodynamic stability, so monitoring vital signs and ensuring hemodynamic support is crucial. Begin with digital compression of the lower third of the nose for 15-20 minutes and ensure the patient leans forward to prevent aspiration. This simple maneuver is often enough to control bleeding in many cases.

If bleeding persists, we move to first-line therapies: apply topical vasoconstrictors like oxymetazoline or phenylephrine, which have proven effective in 65-75% of cases. Topical tranexamic acid (TXA) is a game-changer—studies show it's superior to traditional anterior packing for reducing rebleeding rates within 2 and 7 days. When the bleeding site is visible, electrocautery is the gold standard, leading to faster outcomes with reduced treatment times. If cautery fails, nasal packing is used, preferably resorbable for patients on anticoagulants to reduce trauma risk.

For posterior epistaxis, which is more severe and often requires hospitalization, posterior packing or even balloon tamponade may be necessary. In refractory cases, arterial ligation or endovascular embolization are highly effective, with over 90% success in acute control.

When managing special populations, such as those with hereditary hemorrhagic telangiectasia (HHT), ensure moisturizing therapies, and consider oral tranexamic acid or ablative therapies like laser or radiofrequency ablation for persistent bleeds. For anticoagulated patients, consider temporary reversal of anticoagulation if bleeding is severe.

For discharge planning, focus on education about preventing recurrence—advise humidification and avoiding nasal trauma, and emphasize follow-up with otolaryngology for severe or recurrent cases. Patient education is vital to avoid further injury and to ensure early intervention if bleeding recurs.

Hospital-specific pearls: • Prioritize airway safety and hemodynamic monitoring in all patients with epistaxis. • Use topical TXA as the first-line intervention for rebleeding, followed by electrocautery if the bleeding site is visible. • Resorbable nasal packing is preferred for anticoagulated patients to minimize trauma. • Early involvement of specialists—especially otolaryngologists—is crucial for severe or refractory cases.

We close with system moves: a bundle that (1) triggers TXA administration in cases of epistaxis, (2) prompts electrocautery orders when the bleeding site is identified, (3) auto-orders resorbable packing for anticoagulated patients, (4) sends follow-up reminders for recurrent bleeds, and (5) links to specialist consultations for refractory or complex cases.

Epistaxis care requires prompt diagnosis and intervention—with TXA, cautery, and packing as key components. Proper management reduces complications and improves patient comfort while preventing recurrence.