Epistaxis resident survival guide

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Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amir Behzad Bagheri, M.D.

Synonyms and keywords: Epistaxis approach, An approach to epistaxis, Nose bleeding approach


Epistaxis, also known as nose bleeding, is terminology for bleeding of the nose vessels that drain from the nostrils (most often) and/or nasopharynx. Epistaxis often stops easily but can be an ENT emergency, and may be critical if appropriate action does not occur. Kiesselbach's plexus is the source of most epistaxis.


Based on the cause and severity of Epistaxis, it can be life-threatening.[1] [2] [3]

Life Threatening Causes

Life-threatening causes of epistaxis include conditions that may result in death or permanent disability within 24 hours if left untreated.

Common Causes

There is not enough evidence that hypertension is a risk factor for epistaxis. The role of lowering blood pressure to control and prevent epistaxis remains controversial.


Shown below is an algorithm summarizing the diagnosis of epistaxis according to North America Clinical Practice Guideline.[1] [4] [5] [6] [7]

Patient with Epistaxis?

Take a complete medical history
❑ Recurrent bleeding?
❑ Using anticoagulant or antiplatelet medications?
❑ Recent trauma or surgery
Vascular abnormalities
❑ Family history of epistaxis
❑ Other underlying diseases
-Check the following labs in severe bleeding or with possibility of coagulopathy:

Vascular abnormalities

Trauma is the most frequent cause of epistaxis(17%)
❑ Digital trauma
Facial trauma
Foreign body insertion
Septal perforation
❑ Illicit drugs

Septal deviation
Neoplasia in situ
Renal failure
❑ Hepatic dysfuction
This algorithm developed and modified according to Epistaxis of Emergency Medicine Clinics of North America and Clinical Practice Nosebleed (Epistaxis) Guideline. This guideline was published in the January 2020 issue of the American Academy of Otolaryngology-Head and Neck Surgery.


Shown below is an algorithm summarizing the treatment of epistaxis according to The American Academy of ENT guidelines. [4] [6] [8] [9]

Patient with Epistaxis
First assess ABC*
Need of Immediate Action?
Yes→ :

❑ Assess Airway
Hemodynamic stability
❑ Needs for emergency setting
Active Bleeding ?
Yes→Nasal compression for≥5 min
Bleeding resume
Bleeding Controlled
Rhinoscopy to identify location of bleeding
Risk factor Assessment :

❑ Assess HHT **
❑ Bilateral bleeding
Epistaxis history in Family
Bleeding site identified?
Rhinoscopy to identify location of bleeding
Yes→ Three options:

❑ 1= Lubricants
❑ 2= Topical vasoconstrictors
❑ 3= Nasal cautery
Bleeding site Identified
Bleeding site not identified
Decision for Nausal Cautery?
Anesthesia bleeding site and limit Nasal cautery to site
Yes→ Anesthesia bleeding site and limit Nasal Cautery to site
Bleeding controlled
Bleeding resume
Rist factor assessment
Suspected Bleeding site HHT ** or on anticoagulants?
Patient education and prevention
NO→Non absorbable or Absorbable packing(Preferred in children)
Yes→Absorbable packing
Outcome Assesment
Nasal packing education
Bleeding controlled
Bleeding resume
Patient use anticoagulant or antiplatelet medications
Patient doesn't use anticoagulant or antiplatelet medications
Patient Education and prevention
Life treatening Nose bleeding ?
Outcome Assement
Yes→ Evaluate need for or risk of discontinuation Anti-Coag/Anti-Platelet medications
Bleeding controled
Bleeding resume
Evaluate candidency for embolization or surgical arterial ligation
Appropriate intervention which may include embolization, Surgery, Additional Nasal packing or Cautery
Patient Education and Prevention
Outcome Assesment
This algorithm developed and modified according to Epistaxis of Emergency Medicine Clinics of North America and Clinical Practice Nosebleed (Epistaxis) Guideline. This guideline was published in the January 2020 issue of the American Academy of Otolaryngology-Head and Neck Surgery.




  1. 1.0 1.1 Krulewitz, Neil Alexander; Fix, Megan Leigh (2019). "Epistaxis". Emergency Medicine Clinics of North America. 37 (1): 29–39. doi:10.1016/j.emc.2018.09.005. ISSN 0733-8627.
  2. Douglas, Richard; Wormald, Peter-John (2007). "Update on epistaxis". Current Opinion in Otolaryngology & Head and Neck Surgery. 15 (3): 180–183. doi:10.1097/MOO.0b013e32814b06ed. ISSN 1068-9508.
  3. Kikidis, D.; Tsioufis, K.; Papanikolaou, V.; Zerva, K.; Hantzakos, A. (2013). "Is epistaxis associated with arterial hypertension? A systematic review of the literature". European Archives of Oto-Rhino-Laryngology. 271 (2): 237–243. doi:10.1007/s00405-013-2450-z. ISSN 0937-4477.
  4. 4.0 4.1 4.2 4.3 Tunkel, David E.; Anne, Samantha; Payne, Spencer C.; Ishman, Stacey L.; Rosenfeld, Richard M.; Abramson, Peter J.; Alikhaani, Jacqueline D.; Benoit, Margo McKenna; Bercovitz, Rachel S.; Brown, Michael D.; Chernobilsky, Boris; Feldstein, David A.; Hackell, Jesse M.; Holbrook, Eric H.; Holdsworth, Sarah M.; Lin, Kenneth W.; Lind, Meredith Merz; Poetker, David M.; Riley, Charles A.; Schneider, John S.; Seidman, Michael D.; Vadlamudi, Venu; Valdez, Tulio A.; Nnacheta, Lorraine C.; Monjur, Taskin M. (2020). "Clinical Practice Guideline: Nosebleed (Epistaxis)". Otolaryngology–Head and Neck Surgery. 162 (1_suppl): S1–S38. doi:10.1177/0194599819890327. ISSN 0194-5998.
  5. Thornton, M A.; Mahesh, B N.; Lang, J (2005). "Posterior Epistaxis: Identification of Common Bleeding Sites". The Laryngoscope. 115 (4): 588–590. doi:10.1097/01.mlg.0000161365.96685.6c. ISSN 0023-852X.
  6. 6.0 6.1 Chaaban, Mohamad R.; Zhang, Dong; Resto, Vicente; Goodwin, James S. (2016). "Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis". Otolaryngology–Head and Neck Surgery. 156 (1): 81–86. doi:10.1177/0194599816667295. ISSN 0194-5998.
  7. Viehweg, Tate L.; Roberson, John B.; Hudson, J.W. (2006). "Epistaxis: Diagnosis and Treatment". Journal of Oral and Maxillofacial Surgery. 64 (3): 511–518. doi:10.1016/j.joms.2005.11.031. ISSN 0278-2391.
  8. Béquignon, E; Teissier, N; Gauthier, A; Brugel, L; De Kermadec, H; Coste, A; Prulière-Escabasse, V (2017). "Emergency Department care of childhood epistaxis". Emergency Medicine Journal. 34 (8): 543–548. doi:10.1136/emermed-2015-205528. ISSN 1472-0205.
  9. Escabasse, V.; Bequignon, E.; Vérillaud, B.; Robard, L.; Michel, J.; Malard, O.; Crampette, L.; Malard, O.; Crampette, L.; Achache, M.; Alaoui Lamrani, M.Y.; Ardillon, L.; Babin, E.; Bal Dit Sollier, C.; Bequignon, E.; Borsik, M.; Castillo, L.; Coste, A.; Debry, C.; Dessi, P.; Drouet, L.; Dufour, X.; Dupuis-Girod, S.; Faure, F.; Gallet, P.; Guldman, R.; Houdart, E.; Jankowski, R.; Jegoux, F.; Leble, S.; Michel, J.; Mortuaire, G.; Mouchon, E.; Page, C.; Pruliere Escabasse, V.; Robard, L.; Roux, A.; Saint Maurice, J.P.; Sarlon, G.; Strunski, V.; Trevillot, V.; Verillaud, B.; Vironneau, P. (2017). "Guidelines of the French Society of Otorhinolaryngology (SFORL). Managing epistaxis under coagulation disorder due to antithrombotic therapy". European Annals of Otorhinolaryngology, Head and Neck Diseases. 134 (3): 195–199. doi:10.1016/j.anorl.2016.10.001. ISSN 1879-7296.