Epistaxis resident survival guide

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Epistaxis
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


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

Overview

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.

Causes

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.

Diagnosis

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
Allergies
Cancer
❑ Other underlying diseases
-Check the following labs in severe bleeding or with possibility of coagulopathy:
CBC
PT
PTT

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Trauma
 
 
 
 
Coagulopathy
 
 
 
Vascular abnormalities
 
 
 
 
Others
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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


Sinusitis
Allergies
Septal deviation
Neoplasia in situ
Renal failure
Uremia
❑ Hepatic dysfuction
Idiopathic
Infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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.

Treatment

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
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Active Bleeding ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes→Nasal compression for≥5 min
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding site Identified
 
 
Bleeding site not identified
 
 
 
Decision for Nausal Cautery?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anestesia bleeding site and limit Nasal cautery to site
 
 
 
 
 
 
 
Yes→ Anestesia bleeding site and limit Nasal Cautery to site
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
Discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
No
 
 
 
 
 
 
 
Discharge
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
Discharge
 
 
 
 
 
 
 
 
 
 
 
 
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.

Do's

Don'ts

References

  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.