Epistaxis Initial Stabilization and Site-Directed Management
A multidisciplinary guideline for nosebleed (epistaxis) recommends triaging patients who require prompt management from those who do not at the time of initial contact. [1] Active bleeding in patients needing prompt management should be treated with firm sustained compression to the lower third of the nose for 5 minutes or longer. [1] If bleeding persists after compression prevents identification of the bleeding site, escalation to nasal packing is recommended. [1]
Triage and Initial Assessment
- Clinicians should distinguish at initial contact between nosebleed patients who require prompt management and those who do not. [1]
- Factors that increase bleeding frequency or severity should be documented, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, and intranasal drug use. [1]
First-Line Active Bleeding Maneuvers
- Active bleeding should be treated with firm sustained compression to the lower third of the nose for 5 minutes or longer, with or without assistance from the patient or caregiver. [1]
- After packing placement, patient education should include the type of packing placed, timing and plan for removal when packing is nonresorbable, postprocedure care, and warning signs that warrant prompt reassessment. [1]
Nasal Packing Strategy
- Nasal packing should be used for ongoing active bleeding when compression prevents identification of a bleeding site. [1]
- Resorbable packing should be used for patients with a suspected bleeding disorder or for patients using anticoagulation or antiplatelet medications. [1]
Diagnostic Localization After Hemostasis Attempts
- After removal of any blood clot, anterior rhinoscopy should be performed to identify the source of bleeding for patients with nosebleeds. [1]
- Nasal endoscopy should be performed, or referred for, to identify the bleeding site and guide further management for patients with recurrent nasal bleeding despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. [1]
- Nasal endoscopy may be performed, or referred for, in patients with epistaxis that is difficult to control or when unrecognized pathology is a concern. [1]
Site-Directed Bleeding Control
When a bleeding site is identified, the guideline recommends an appropriate intervention that may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents. [1] When nasal cautery is selected, anesthetization of the bleeding site is recommended, with restriction of cautery application to the active or suspected site(s) of bleeding. [1]
Escalation for Persistent or Recurrent Hemorrhage
For persistent or recurrent bleeding not controlled by packing or nasal cauterization, candidacy for surgical arterial ligation or endovascular embolization should be evaluated, or referred for evaluation. [1]
Anticoagulation, Transfusion, and Reversal Sequence
In the absence of life-threatening bleeding, first-line treatments should be initiated prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation or antiplatelet medications for patients using these agents. [1]
Hereditary Hemorrhagic Telangiectasia Evaluation and Prevention
- Presence of nasal telangiectasias and/or oral mucosal telangiectasias should be assessed, or referred for assessment, in patients with recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome. [1]
- Patients and caregivers should receive education on preventive measures, home treatment for nosebleeds, and indications to seek additional medical care. [1]
Follow-Up Documentation
- Outcomes of intervention should be documented within 30 days, or transition of care should be documented, for patients treated with nonresorbable packing, surgery, or arterial ligation or embolization. [1]