Initial Workup and Management of Massive Epistaxis

Immediate Triage and Stabilization

The American Academy of Otolaryngology-Head and Neck Surgery recommends immediate assessment of airway patency and hemodynamic stability, while applying firm nasal compression, for patients with massive epistaxis 1
Massive epistaxis requires emergent evaluation in a hospital or emergency department setting when there is active bleeding with airway compromise, hemodynamic instability, or signs of significant blood loss 1
Firm sustained compression to the lower third of the nose for at least 5-10 minutes is the single most effective first-line intervention for massive epistaxis 1
The American Academy of Otolaryngology-Head and Neck Surgery suggests treating ongoing active bleeding with nasal packing if compression fails 1

A history of bleeding characteristics, such as duration >30 minutes over 24 hours, indicates severe epistaxis requiring aggressive management 1
Bilateral bleeding or bleeding from the mouth suggests a posterior source of epistaxis 1
A history of hospitalization or prior blood transfusion for epistaxis indicates a high-risk patient 1
The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting all anticoagulants and antiplatelet agents, as these patients require resorbable packing materials only 2

A complete blood count (CBC) is mandatory to assess for anemia and quantify blood loss severity, with a hemoglobin drop ≥2 g/dL indicating major bleeding requiring aggressive management 2
Prothrombin time (PT)/International Normalized Ratio (INR) and activated partial thromboplastin time (aPTT) should be obtained in all patients on anticoagulation or with clinically relevant bleeding 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends removing blood clots by suction or gentle nose blowing to identify the bleeding source 4
Anterior rhinoscopy should be performed to examine the nasal septum, as most nosebleeds originate from the anterior septum (Kiesselbach's plexus/Little's area) 1
Nasal endoscopy must be performed or referred when bleeding is difficult to control, anterior rhinoscopy fails to identify the source, or there is concern for unrecognized pathology 4

For posterior epistaxis or bleeding refractory to initial measures, posterior nasal packing with Foley catheter and tranexamic acid-soaked gauze may be necessary 3
Only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) should be used in patients on anticoagulants to reduce trauma during removal 2

If nasal packing fails or bleeding recurs, evaluate candidacy for surgical arterial ligation or endovascular embolization, with endoscopic sphenopalatine artery ligation having a 97% success rate and endovascular embolization having an 80% success rate 3