Epistaxis Management Guidelines

Initial Assessment and Triage

The American Academy of Otolaryngology-Head and Neck Surgery recommends immediate triage to determine if the patient requires emergent versus routine evaluation, followed by anterior rhinoscopy to identify the bleeding source, with laboratory testing reserved for patients with severe bleeding, anticoagulation use, or suspected bleeding disorders 1, 2
Emergent evaluation is required for patients with active bleeding and airway compromise, hemodynamic instability, or signs of significant blood loss 1, 2, 3
Prompt ambulatory evaluation is recommended for patients with minor active bleeding without airway or hemodynamic compromise, but with clinical expertise and supplies available 1, 2
Routine office evaluation is suitable for patients with no active bleeding, prior bleeding was minor, and no concern for severe recurrence 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery suggests documenting specific factors that predict severity and guide management, including bleeding characteristics, medication history, comorbidities, prior epistaxis management, and family history 1, 4
Bleeding characteristics, such as duration >30 minutes over 24 hours, indicate severe epistaxis, while >3 recent episodes suggest the need for specialist evaluation 1, 4, 5
Medication history, including anticoagulants and antiplatelet agents, is crucial, as these patients require resorbable packing if intervention is needed 1, 4, 6
Comorbidities, such as hypertension, cardiovascular disease, renal disease, liver disease, anemia, and bleeding disorders, should be documented 1, 4, 3

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing systematic visualization to identify the bleeding source, starting with anterior rhinoscopy, which is essential for identifying the bleeding site 1, 2
Anterior rhinoscopy should be performed after removing blood clots, and the nasal septum should be examined, as most nosebleeds originate from the anterior septum (Kiesselbach's plexus/Little's area) 1, 2, 4, 7
Nasal endoscopy should be performed or referred when bleeding is difficult to control, or there is concern for unrecognized pathology (tumors, vascular malformations), or anterior rhinoscopy fails to identify the source 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery suggests that laboratory workup is not routine and should be reserved for specific clinical scenarios, such as patients with frequent/profuse bleeding, anticoagulation use, or suspected bleeding disorders 3, 4, 8
Complete blood count (CBC) should be obtained in patients with frequent/profuse bleeding to assess for anemia and quantify blood loss severity, and hemoglobin drop ≥2 g/dL indicates major bleeding requiring aggressive management 3
PT/INR and aPTT should be obtained in all patients on anticoagulation or with clinically relevant bleeding 3

The American Academy of Otolaryngology-Head and Neck Surgery recommends recording specific factors that increase bleeding frequency or severity, including bleeding duration, frequency, and estimated volume, anticoagulation/antiplatelet medication use, comorbid conditions, prior treatments attempted, and their effectiveness 1, 2
Outcome of intervention within 30 days or document transition of care should be recorded 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery advises against skipping clot removal before attempting visualization, as this prevents accurate identification of the bleeding source 1, 2
Non-resorbable packing should not be used in patients with bleeding disorders or on anticoagulation; instead, resorbable materials should be used 1, 2, 6