Epistaxis resident survival guide: Difference between revisions

Jump to navigation Jump to search
No edit summary
 
(19 intermediate revisions by 3 users not shown)
Line 1: Line 1:
<div style="width: 1px; height: 1px; background-color: #999999; position: fixed; top: 10px; left: 10px"></div>
<div style="width: 1px; height: 1px; background-color: #999999; position: fixed; top: 10px; left: 10px"></div>
<div style="width: 90%; -webkit-user-select: none;">
<div style="width: 90%; -webkit-user-select: none;">
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0";
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0" ;
|-
|-
! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align=center| {{fontcolor|#2B3B44|Epistaxis <BR>Resident Survival Guide}}
! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align="center" |{{fontcolor|#2B3B44|Epistaxis <BR>Resident Survival Guide}}
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Overview|Overview]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Overview|Overview]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Causes|Causes]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Diagnosis|Diagnosis]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Diagnosis|Diagnosis]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Treatment|Treatment]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Treatment|Treatment]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Do's|Do's]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Do's|Do's]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align=left | [[{{PAGENAME}}#Don'ts|Don'ts]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Don'ts|Don'ts]]
|}
|}
__NOTOC__
__NOTOC__
{{WikiDoc CMG}}; {{AE}} [[User:Amir Bagheri|Amir Behzad Bagheri, M.D.]]
{{WikiDoc CMG}}; {{AE}} [[User:Amir Bagheri|Amir Behzad Bagheri, M.D.]]


{{SK}} Epistaxis approach, An approach to epistaxis, Nose bleeding approach
{{SK}} Epistaxis approach, An approach to epistaxis, Nose bleeding approach
==Overview==
==Overview==
Epistaxis, also known as, noes [[bleeding]], is a terminology name for [[bleeding]] of the nose [[vessels]] that drains out from nostril (most often) and/or [[nasopharynx]]. Epistaxis often stops easily but sometimes it's an ENT emergency which can be critical if appropriate action does not occur.  Kiesselbach's plexus is the source of most epistaxis.
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==
==Causes==
Base on the cause and severity of Epistaxis it can be life-threatening.<ref name="KrulewitzFix2019">{{cite journal|last1=Krulewitz|first1=Neil Alexander|last2=Fix|first2=Megan Leigh|title=Epistaxis|journal=Emergency Medicine Clinics of North America|volume=37|issue=1|year=2019|pages=29–39|issn=07338627|doi=10.1016/j.emc.2018.09.005}}</ref> <ref name="DouglasWormald2007">{{cite journal|last1=Douglas|first1=Richard|last2=Wormald|first2=Peter-John|title=Update on epistaxis|journal=Current Opinion in Otolaryngology & Head and Neck Surgery|volume=15|issue=3|year=2007|pages=180–183|issn=1068-9508|doi=10.1097/MOO.0b013e32814b06ed}}</ref><ref name="KikidisTsioufis2013">{{cite journal|last1=Kikidis|first1=D.|last2=Tsioufis|first2=K.|last3=Papanikolaou|first3=V.|last4=Zerva|first4=K.|last5=Hantzakos|first5=A.|title=Is epistaxis associated with arterial hypertension? A systematic review of the literature|journal=European Archives of Oto-Rhino-Laryngology|volume=271|issue=2|year=2013|pages=237–243|issn=0937-4477|doi=10.1007/s00405-013-2450-z}}</ref>
Based on the cause and severity of Epistaxis, it can be life-threatening.<ref name="KrulewitzFix2019">{{cite journal|last1=Krulewitz|first1=Neil Alexander|last2=Fix|first2=Megan Leigh|title=Epistaxis|journal=Emergency Medicine Clinics of North America|volume=37|issue=1|year=2019|pages=29–39|issn=07338627|doi=10.1016/j.emc.2018.09.005}}</ref> <ref name="DouglasWormald2007">{{cite journal|last1=Douglas|first1=Richard|last2=Wormald|first2=Peter-John|title=Update on epistaxis|journal=Current Opinion in Otolaryngology & Head and Neck Surgery|volume=15|issue=3|year=2007|pages=180–183|issn=1068-9508|doi=10.1097/MOO.0b013e32814b06ed}}</ref> <ref name="KikidisTsioufis2013">{{cite journal|last1=Kikidis|first1=D.|last2=Tsioufis|first2=K.|last3=Papanikolaou|first3=V.|last4=Zerva|first4=K.|last5=Hantzakos|first5=A.|title=Is epistaxis associated with arterial hypertension? A systematic review of the literature|journal=European Archives of Oto-Rhino-Laryngology|volume=271|issue=2|year=2013|pages=237–243|issn=0937-4477|doi=10.1007/s00405-013-2450-z}}</ref>


===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes of epistaxis include [[conditions]] that may result in death or permanent disability within 24 hours if left untreated.
Life-threatening causes of epistaxis include [[conditions]] that may result in death or permanent disability within 24 hours if left untreated.
* [[Haemophilia]]
 
* [[Congestive heart failure]]
*[[Haemophilia]]
* [[ITP]]
*[[Congestive heart failure]]
* [[Leukemia]]  
*[[ITP]]
*[[Leukemia]]


===Common Causes===
===Common Causes===
* Local [[trauma]]
* [[Acute sinusitis]]
* [[Allergic rhinitis]]
* [[Anticoagulation]]
* [[Aspirin]]
* [[Rhinitis|Chronic rhinitis]]
* [[Chronic sinusitis]]
* [[Barotrauma]]
* [[Cocaine]]
* [[Common cold]]
* [[Foreign bodies]]
* [[Nose-picking]]
* [[Neoplasia]]


There is not enough evidence that [[hypertension]] is a risk factor for [[epistaxis]], and lowering [[blood pressure]] to controll and prevention of [[epistaxis]] is controversial.
*Local [[trauma]]
*[[Acute sinusitis]]
*[[Allergic rhinitis]]
*[[Anticoagulation]]
*[[Aspirin]]
*[[Rhinitis|Chronic rhinitis]]
*[[Chronic sinusitis]]
*[[Barotrauma]]
*[[Cocaine]]
*[[Common cold]]
*[[Foreign bodies]]
*[[Nose-picking]]
*[[Neoplasia]]
 
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==
==Diagnosis==
Shown below is an algorithm summarizing the [[diagnosis]] of Epistaxis 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.<ref name="KrulewitzFix2019">{{cite journal|last1=Krulewitz|first1=Neil Alexander|last2=Fix|first2=Megan Leigh|title=Epistaxis|journal=Emergency Medicine Clinics of North America|volume=37|issue=1|year=2019|pages=29–39|issn=07338627|doi=10.1016/j.emc.2018.09.005}}</ref> <ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref> <ref name="ThorntonMahesh2005">{{cite journal|last1=Thornton|first1=M A.|last2=Mahesh|first2=B N.|last3=Lang|first3=J|title=Posterior Epistaxis: Identification of Common Bleeding Sites|journal=The Laryngoscope|volume=115|issue=4|year=2005|pages=588–590|issn=0023852X|doi=10.1097/01.mlg.0000161365.96685.6c}}</ref> <ref name="ChaabanZhang2016">{{cite journal|last1=Chaaban|first1=Mohamad R.|last2=Zhang|first2=Dong|last3=Resto|first3=Vicente|last4=Goodwin|first4=James S.|title=Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis|journal=Otolaryngology–Head and Neck Surgery|volume=156|issue=1|year=2016|pages=81–86|issn=0194-5998|doi=10.1177/0194599816667295}}</ref> <ref name="ViehwegRoberson2006">{{cite journal|last1=Viehweg|first1=Tate L.|last2=Roberson|first2=John B.|last3=Hudson|first3=J.W.|title=Epistaxis: Diagnosis and Treatment|journal=Journal of Oral and Maxillofacial Surgery|volume=64|issue=3|year=2006|pages=511–518|issn=02782391|doi=10.1016/j.joms.2005.11.031}}</ref>
Shown below is an algorithm summarizing the [[diagnosis]] of epistaxis according to North America Clinical Practice Guideline.<ref name="KrulewitzFix2019">{{cite journal|last1=Krulewitz|first1=Neil Alexander|last2=Fix|first2=Megan Leigh|title=Epistaxis|journal=Emergency Medicine Clinics of North America|volume=37|issue=1|year=2019|pages=29–39|issn=07338627|doi=10.1016/j.emc.2018.09.005}}</ref> <ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref> <ref name="ThorntonMahesh2005">{{cite journal|last1=Thornton|first1=M A.|last2=Mahesh|first2=B N.|last3=Lang|first3=J|title=Posterior Epistaxis: Identification of Common Bleeding Sites|journal=The Laryngoscope|volume=115|issue=4|year=2005|pages=588–590|issn=0023852X|doi=10.1097/01.mlg.0000161365.96685.6c}}</ref> <ref name="ChaabanZhang2016">{{cite journal|last1=Chaaban|first1=Mohamad R.|last2=Zhang|first2=Dong|last3=Resto|first3=Vicente|last4=Goodwin|first4=James S.|title=Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis|journal=Otolaryngology–Head and Neck Surgery|volume=156|issue=1|year=2016|pages=81–86|issn=0194-5998|doi=10.1177/0194599816667295}}</ref> <ref name="ViehwegRoberson2006">{{cite journal|last1=Viehweg|first1=Tate L.|last2=Roberson|first2=John B.|last3=Hudson|first3=J.W.|title=Epistaxis: Diagnosis and Treatment|journal=Journal of Oral and Maxillofacial Surgery|volume=64|issue=3|year=2006|pages=511–518|issn=02782391|doi=10.1016/j.joms.2005.11.031}}</ref>
 




Line 60: Line 61:
{{Family tree | | | | | | | | | | | | A01 | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: 27em; width: 16em; padding:1em;"> '''Patient with [[Epistaxis]]?'''<br>
{{Family tree | | | | | | | | | | | | A01 | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: 27em; width: 16em; padding:1em;"> '''Patient with [[Epistaxis]]?'''<br>
----
----
Take a complete medical history <br> ❑ Recurrent bleeding? <br> ❑ Using [[anticoagulant]] or [[antiplatelet]] [[medications]]? <br> ❑ Recent trauma or [[surgery]] <br> ❑ [[Vascular abnormalitie]]s<br> ❑ Family history of [[epistaxis]] <br>❑ [[Allergies]]<br> ❑ [[Cancer]] <br> ❑ Other undelying diseases <br> -Check the following labs in severe bleeding or with possibility of [[coagulopathy]]:<br>
Take a complete medical history <br> ❑ Recurrent [[bleeding]]? <br> ❑ Using [[anticoagulant]] or [[antiplatelet]] [[medications]]? <br> ❑ Recent [[trauma]] or [[surgery]] <br> ❑ [[Vascular abnormalitie]]s<br> ❑ Family history of [[epistaxis]] <br>❑ [[Allergies]]<br> ❑ [[Cancer]] <br> ❑ Other underlying [[diseases]] <br> -Check the following labs in severe [[bleeding]] or with possibility of [[coagulopathy]]:<br>
❑ [[CBC]]<br>
❑ [[CBC]]<br>
❑ [[PT]]<br>
❑ [[PT]]<br>
Line 72: Line 73:
{{Family tree |boxstyle=background: #FA8072; color: #F8F8FF;| | C01 | | | | | C02 | | | | C03 | | | | | C04 | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: 14em; width: 15em; padding:1em;">  
{{Family tree |boxstyle=background: #FA8072; color: #F8F8FF;| | C01 | | | | | C02 | | | | C03 | | | | | C04 | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: 14em; width: 15em; padding:1em;">  
----
----
'''Trauma is the most cause of epistaxis(17%)<br> ❑ Digital [[trauma]] <br> ❑ [[Facial trauma]] <br> ❑ [[Foreign body]] insertion <br> ❑ [[Septal]] perforation <br> ❑ [[Barotrauma]] <br> ❑ Illicit drugs  </div> |C02=<div style="float: left; text-align: left; height: 14em; width: 15em; padding:1em;">  
'''[[Trauma]] is the most frequent [[cause]] of epistaxis(17%)<br> ❑ Digital [[trauma]] <br> ❑ [[Facial trauma]] <br> ❑ [[Foreign body]] insertion <br> ❑ [[Septal]] perforation <br> ❑ [[Barotrauma]] <br> ❑ Illicit drugs  </div> |C02=<div style="float: left; text-align: left; height: 14em; width: 15em; padding:1em;">  
----
----
  '''❑ Using [[Anticoagulants]] or [[Antiplatelet]] medications<br> ❑ [[ITP]]* <br> ❑ [[von Willebrand disease]] <br> ❑ [[Leukemia]] <br>❑ Other medications cause [[coagulopathy]] </div> | C03= <div style="float: left; text-align: left; height: 14em; width: 15em; padding:1em;">'''  
  '''❑ Using [[Anticoagulants]] or [[Antiplatelet]] [[medications]]<br> ❑ [[ITP]]* <br> ❑ [[von Willebrand disease]] <br> ❑ [[Leukemia]] <br>❑ Other [[medications]] causing [[coagulopathy]] </div> | C03= <div style="float: left; text-align: left; height: 14em; width: 15em; padding:1em;">'''  
----
----
  '''❑ [[HHT]]** <br> ❑ [[Congestive heart failure]] <br> ❑ [[Granulomatosis with polyangitis]] </div> | C04= <div style="float: left; text-align: left; height: 16em; width: 15em; padding:1em;"> '''<span style="color:navy;"></span>'''<br>'''
  '''❑ [[HHT]]** <br> ❑ [[Congestive heart failure]] <br> ❑ [[Granulomatosis with polyangitis]] </div> | C04= <div style="float: left; text-align: left; height: 16em; width: 15em; padding:1em;"> '''<span style="color:navy;"></span>'''<br>'''
----
----
  '''❑[[Sinusitis]] <br> ❑ [[Allergies]] <br> ❑ [[Septal]] deviation <br> ❑ [[Neoplasia]] in situ <br> ❑ [[Renal failure]] <br> ❑ [[Uremia]] <br> ❑ Hepatic dysfuction <br> ❑ [[Idiopathic]] <br> ❑ [[Infection]]</div>}}  
  '''❑ [[Sinusitis]] <br> ❑ [[Allergies]] <br> ❑ [[Septal]] deviation <br> ❑ [[Neoplasia]] in situ <br> ❑ [[Renal failure]] <br> ❑ [[Uremia]] <br> ❑ Hepatic dysfuction <br> ❑ [[Idiopathic]] <br> ❑ [[Infection]]</div>}}  
{{familytree/end}}'''
{{familytree/end}}


* [[ITP]] = [[Immune thrombocytopenic purpura]]
*[[ITP]] = [[Immune thrombocytopenic purpura]]
* [[HHT]] = [[Hereditary Hemorrhagic Telangiectasia]]
*[[HHT]] = [[Hereditary Hemorrhagic Telangiectasia]]


{|
{|
Line 90: Line 91:


==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of <nowiki>[[Epistaxis]]</nowiki> according to The American Academy of [[ENT]] guidelines. <ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref>
Shown below is an algorithm summarizing the treatment of [[epistaxis]] according to The American Academy of [[ENT]] guidelines. <ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref>
<ref name="ChaabanZhang2016">{{cite journal|last1=Chaaban|first1=Mohamad R.|last2=Zhang|first2=Dong|last3=Resto|first3=Vicente|last4=Goodwin|first4=James S.|title=Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis|journal=Otolaryngology–Head and Neck Surgery|volume=156|issue=1|year=2016|pages=81–86|issn=0194-5998|doi=10.1177/0194599816667295}}</ref> <ref name="BéquignonTeissier2017">{{cite journal|last1=Béquignon|first1=E|last2=Teissier|first2=N|last3=Gauthier|first3=A|last4=Brugel|first4=L|last5=De Kermadec|first5=H|last6=Coste|first6=A|last7=Prulière-Escabasse|first7=V|title=Emergency Department care of childhood epistaxis|journal=Emergency Medicine Journal|volume=34|issue=8|year=2017|pages=543–548|issn=1472-0205|doi=10.1136/emermed-2015-205528}}</ref>
<ref name="ChaabanZhang2016">{{cite journal|last1=Chaaban|first1=Mohamad R.|last2=Zhang|first2=Dong|last3=Resto|first3=Vicente|last4=Goodwin|first4=James S.|title=Demographic, Seasonal, and Geographic Differences in Emergency Department Visits for Epistaxis|journal=Otolaryngology–Head and Neck Surgery|volume=156|issue=1|year=2016|pages=81–86|issn=0194-5998|doi=10.1177/0194599816667295}}</ref> <ref name="BéquignonTeissier2017">{{cite journal|last1=Béquignon|first1=E|last2=Teissier|first2=N|last3=Gauthier|first3=A|last4=Brugel|first4=L|last5=De Kermadec|first5=H|last6=Coste|first6=A|last7=Prulière-Escabasse|first7=V|title=Emergency Department care of childhood epistaxis|journal=Emergency Medicine Journal|volume=34|issue=8|year=2017|pages=543–548|issn=1472-0205|doi=10.1136/emermed-2015-205528}}</ref>
<ref name="EscabasseBequignon2017">{{cite journal|last1=Escabasse|first1=V.|last2=Bequignon|first2=E.|last3=Vérillaud|first3=B.|last4=Robard|first4=L.|last5=Michel|first5=J.|last6=Malard|first6=O.|last7=Crampette|first7=L.|last8=Malard|first8=O.|last9=Crampette|first9=L.|last10=Achache|first10=M.|last11=Alaoui Lamrani|first11=M.Y.|last12=Ardillon|first12=L.|last13=Babin|first13=E.|last14=Bal Dit Sollier|first14=C.|last15=Bequignon|first15=E.|last16=Borsik|first16=M.|last17=Castillo|first17=L.|last18=Coste|first18=A.|last19=Debry|first19=C.|last20=Dessi|first20=P.|last21=Drouet|first21=L.|last22=Dufour|first22=X.|last23=Dupuis-Girod|first23=S.|last24=Faure|first24=F.|last25=Gallet|first25=P.|last26=Guldman|first26=R.|last27=Houdart|first27=E.|last28=Jankowski|first28=R.|last29=Jegoux|first29=F.|last30=Leble|first30=S.|last31=Michel|first31=J.|last32=Mortuaire|first32=G.|last33=Mouchon|first33=E.|last34=Page|first34=C.|last35=Pruliere Escabasse|first35=V.|last36=Robard|first36=L.|last37=Roux|first37=A.|last38=Saint Maurice|first38=J.P.|last39=Sarlon|first39=G.|last40=Strunski|first40=V.|last41=Trevillot|first41=V.|last42=Verillaud|first42=B.|last43=Vironneau|first43=P.|title=Guidelines of the French Society of Otorhinolaryngology (SFORL). Managing epistaxis under coagulation disorder due to antithrombotic therapy|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=134|issue=3|year=2017|pages=195–199|issn=18797296|doi=10.1016/j.anorl.2016.10.001}}</ref>
<ref name="EscabasseBequignon2017">{{cite journal|last1=Escabasse|first1=V.|last2=Bequignon|first2=E.|last3=Vérillaud|first3=B.|last4=Robard|first4=L.|last5=Michel|first5=J.|last6=Malard|first6=O.|last7=Crampette|first7=L.|last8=Malard|first8=O.|last9=Crampette|first9=L.|last10=Achache|first10=M.|last11=Alaoui Lamrani|first11=M.Y.|last12=Ardillon|first12=L.|last13=Babin|first13=E.|last14=Bal Dit Sollier|first14=C.|last15=Bequignon|first15=E.|last16=Borsik|first16=M.|last17=Castillo|first17=L.|last18=Coste|first18=A.|last19=Debry|first19=C.|last20=Dessi|first20=P.|last21=Drouet|first21=L.|last22=Dufour|first22=X.|last23=Dupuis-Girod|first23=S.|last24=Faure|first24=F.|last25=Gallet|first25=P.|last26=Guldman|first26=R.|last27=Houdart|first27=E.|last28=Jankowski|first28=R.|last29=Jegoux|first29=F.|last30=Leble|first30=S.|last31=Michel|first31=J.|last32=Mortuaire|first32=G.|last33=Mouchon|first33=E.|last34=Page|first34=C.|last35=Pruliere Escabasse|first35=V.|last36=Robard|first36=L.|last37=Roux|first37=A.|last38=Saint Maurice|first38=J.P.|last39=Sarlon|first39=G.|last40=Strunski|first40=V.|last41=Trevillot|first41=V.|last42=Verillaud|first42=B.|last43=Vironneau|first43=P.|title=Guidelines of the French Society of Otorhinolaryngology (SFORL). Managing epistaxis under coagulation disorder due to antithrombotic therapy|journal=European Annals of Otorhinolaryngology, Head and Neck Diseases|volume=134|issue=3|year=2017|pages=195–199|issn=18797296|doi=10.1016/j.anorl.2016.10.001}}</ref>




{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | | A01 | | | | |A01=Patient with [[Epistaxis]] }}
{{familytree | | | | | | | | | | A01 | | | | |A01=[[Patient]] with [[Epistaxis]] }}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | A02 | | | | | |A02=First assess  '''ABC''' }}
{{familytree | | | | | | | | | | A02 | | | | | |A02=First assess  '''ABC'''* }}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | A02 | | | | | |A02=Need of [[Immediate Action]]? }}
{{familytree | | | | | | | | | | A02 | | | | | |A02=Need of [[Immediate Action]]? }}
Line 108: Line 108:
{{Familytree | | | |!| | | | | | | | | | | | | | |!| }}
{{Familytree | | | |!| | | | | | | | | | | | | | |!| }}
{{familytree | | | |`|-|-|-|-|-|-|-|-|v|-|-|-|-|-|'| | | | }}
{{familytree | | | |`|-|-|-|-|-|-|-|-|v|-|-|-|-|-|'| | | | }}
{{familytree | | | | | | | | | | | | C01 | | | | | | | |C01= [[Active Bleeding]] ? }}
{{familytree | | | | | | | | | | | | C01 | | | | | | | |C01= Active [[Bleeding]] ? }}
{{familytree | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | }}
{{familytree | | | | | |,|-|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | }}
{{Familytree | | | | | |!| | | | | | | | | | | | |!| }}
{{Familytree | | | | | |!| | | | | | | | | | | | |!| }}
{{familytree | | | | | D01 | | | | | | | | | | | D02 | |D01=Yes→[[Nasal compression]] for≥5 min| D02=No}}
{{familytree | | | | | D01 | | | | | | | | | | | D02 | |D01=Yes→[[Nasal compression]] for≥5 min| D02=No}}
{{familytree | | | |,|-|^|.| | | | | | | | | | | |!| | | | }}
{{familytree | | | |,|-|^|.| | | | | | | | | | | |!| | | | }}
{{familytree | | E01 | | E02 | | | | | | | | | | |!| | | | | |E01=Bleeding resume|E02=Bleeding Controlled }}
{{familytree | | E01 | | E02 | | | | | | | | | | |!| | | | | |E01=[[Bleeding]] resume|E02=[[Bleeding]] Controlled }}
{{familytree | | | |!| | |`|-|-|-|-|-|-|-|-|-|-| E03 | | | | | |E03=[[Rhinoscopy]] to identify location of bleeding}}
{{familytree | | | |!| | |`|-|-|-|-|-|-|-|-|-|-| E03 | | | | | |E03=[[Rhinoscopy]] to identify location of [[bleeding]]}}
{{familytree | | | |!| | | | | | | | | | | | | | |!| | | | | | }}
{{familytree | | | |!| | | | | | | | | | | | | | |!| | | | | | }}
{{familytree | | | F01 | | | | | | | | | | | | | F02 | | |F01=<div style="float: left; text-align: left; height: 7em; width: 14em; padding:1em;"> '''Risk factor Assessment :'''<br>
{{familytree | | | F01 | | | | | | | | | | | | | F02 | | |F01=<div style="float: left; text-align: left; height: 7em; width: 14em; padding:1em;"> '''Risk factor Assessment :'''<br>
----
----
❑ Assess [[HHT]]  <br> ❑ Bilateral bleeding <br> ❑ [[Epistaxis]] history in Family  <br> </div>|F02=Bleeding site identified?}}
❑ Assess [[HHT]] ** <br> ❑ Bilateral [[bleeding]] <br> ❑ [[Epistaxis]] history in Family  <br> </div>|F02=[[Bleeding]] site identified?}}
{{familytree | | | |!| | | | | | | | | | | |,|-|-|^|-|-|.| | | }}
{{familytree | | | |!| | | | | | | | | | | |,|-|-|^|-|-|.| | | }}
{{familytree | | | | G01 | | | | | | | | G03 | | | | | G04 | | | | |G01=[[Rhinoscopy]] to identify location of [[bleeding]]| G03=<div style="float: left; text-align: left; height: 7em; width: 14em; padding:1em;"> '''Yes→ Three options:'''<br>
{{familytree | | | | G01 | | | | | | | | G03 | | | | | G04 | | | | |G01=[[Rhinoscopy]] to identify location of [[bleeding]]| G03=<div style="float: left; text-align: left; height: 7em; width: 14em; padding:1em;"> '''Yes→ Three options:'''<br>
Line 124: Line 124:
❑ 1= [[Lubricant]]s <br> ❑ 2= Topical [[vasoconstrictor]]s <br> ❑ 3= Nasal [[cautery]] </div>| G04=No}}
❑ 1= [[Lubricant]]s <br> ❑ 2= Topical [[vasoconstrictor]]s <br> ❑ 3= Nasal [[cautery]] </div>| G04=No}}
{{familytree | | | |,|^|-|-|-|.| | | | | |!| | | | | | |!| | | }}
{{familytree | | | |,|^|-|-|-|.| | | | | |!| | | | | | |!| | | }}
{{familytree | | | H01 | | | H02 | | | | H03 | | | | | |!| | | |H01=Bleeding site Identified|H02=Bleeding site not identified| H03=Decision for Nausal [[Cautery]]? | H04= }}
{{familytree | | | H01 | | | H02 | | | | H03 | | | | | |!| | | |H01=Bleeding site Identified|H02=[[Bleeding]] site not identified| H03=Decision for Nausal [[Cautery]]? | H04= }}
{{familytree | | | |!| | | | |!| | | |,|-|^|.| | | | | |!| | | | }}
{{familytree | | | |!| | | | |!| | | |,|-|^|.| | | | | |!| | | | }}
{{familytree | | | I01 | | | |!| | | I02 | | I03 | | | |!| | | |I01=[[Anestesia]] bleeding site and limit [[Nasal cautery]] to site|I02=Yes→ [[Anestesia]] bleeding site and limit Nasal [[Cautery]] to site | I03=No | I04= }}
{{familytree | | | I01 | | | |!| | | I02 | | I03 | | | |!| | | |I01=[[Anesthesia]] [[bleeding]] site and limit Nasal [[cautery]] to site|I02=Yes→ [[Anesthesia]] [[bleeding]] site and limit Nasal [[Cautery]] to site | I03=No | I04= }}
{{familytree | |,|-|^|-|.| | |!| | | |!| | | |!| | | | |!| | |}}
{{familytree | |,|-|^|-|.| | |!| | | |!| | | |!| | | | |!| | |}}
{{familytree | J01 | | J02 | |!| | | |`|-|-|-|^|-|-|-| J03 | | |J01= [[Bleeding]] controlled|J02= [[Bleeding]] resume|J03=[[Rist factor]] assessment}}
{{familytree | J01 | | J02 | |!| | | |`|-|-|-|^|-|-|-| J03 | | |J01= [[Bleeding]] controlled|J02= [[Bleeding]] resume|J03=[[Rist factor]] assessment}}
{{familytree | |!| | | |!| | |!| | | | | | | | | | | | |!| | | | | |}}
{{familytree | |!| | | |!| | |!| | | | | | | | | | | | |!| | | | | |}}
{{familytree | |!| | | |`|-|-| K02 | | | | | | | | | | K03 | |K01=K01|K02=Suspected [[Bleeding]] site [[HHT]]** or Anticoagulants?| K03=Patient education and [[prevention]] }}
{{familytree | |!| | | |`|-|-| K02 | | | | | | | | | | K03 | |K01=K01|K02=Suspected [[Bleeding]] site [[HHT]] ** or on [[anticoagulant]]s?| K03=[[Patient]] education and [[prevention]] }}
{{Familytree | |!| | | | | |,|-|-|^|-|-|.| | | | | | | |!| }}
{{Familytree | |!| | | | | |,|-|-|^|-|-|.| | | | | | | |!| }}
{{Familytree | |!| | | | | E01 | | | | E02 | | | | | | E03 | | | | | |E01=NO→[[Non absorbable]] or [[Absorbable packing]](Preferred in children)| E02=Yes→[[Absorbable packing]]| E03=Outcome Assesment}}
{{Familytree | |!| | | | | E01 | | | | E02 | | | | | | E03 | | | | | |E01=NO→[[Non absorbable]] or [[Absorbable packing]](Preferred in children)| E02=Yes→[[Absorbable packing]]| E03=Outcome Assesment}}
Line 139: Line 139:
{{Familytree | |!| | | | | G01 | | | G02 | | | | | | | |G01= [[Bleeding]] controlled| G02= [[Bleeding]] resume}}
{{Familytree | |!| | | | | G01 | | | G02 | | | | | | | |G01= [[Bleeding]] controlled| G02= [[Bleeding]] resume}}
{{Familytree | |!| | | | | |!| | |,|-|^|-|-|-|.| | | | | }}
{{Familytree | |!| | | | | |!| | |,|-|^|-|-|-|.| | | | | }}
{{Familytree | |!| | | | | |!| | | H03 | | | H02 | | | | | | | |H01=| H02=Patient '''doesn't use''' [[anticoagulant]] or [[antiplatelet]] medications | H03=Patient use [[anticoagulant]] or [[antiplatelet]] medications }}
{{Familytree | |!| | | | | |!| | | H03 | | | H02 | | | | | | | |H01=| H02=[[Patient]] '''doesn't use''' [[anticoagulant]] or [[antiplatelet]] [[medications]] | H03=[[Patient]] use [[anticoagulant]] or [[antiplatelet]] [[medications]] }}
{{Familytree | |`|-| H01 |-|'| | |!| | | | | |!| | H01=Patient Education and [[prevention]] }}
{{Familytree | |`|-| H01 |-|'| | |!| | | | | |!| | H01=[[Patient]] Education and [[prevention]] }}
{{Familytree | | | | |!| | | | | | I03 | | | |!| | |I01=I01| I02=I02| I03=[[Life treatening]] Nose [[bleeding]] ?}}
{{Familytree | | | | |!| | | | | | I03 | | | |!| | |I01=I01| I02=I02| I03=[[Life treatening]] Nose [[bleeding]] ?}}
{{Familytree | | | | B01 | | | |,|-|^|-|.| | |!| | | B01=Outcome Assement }}
{{Familytree | | | | B01 | | | |,|-|^|-|.| | |!| | | B01=Outcome Assement }}
{{Familytree | | | | |!| | | | | J02 | | J03 |!| | |J01=| J02=Yes→ Evaluate need for or risk of discontinuation [[Anti-Coag]]/[[Anti-Platelet]] medications | J03=No }}
{{Familytree | | | | |!| | | | J02 | | J03 | |!| |J01=| J02=Yes→ Evaluate need for or risk of discontinuation [[Anti-Coag]]/[[Anti-Platelet]] medications | J03=No }}
{{Familytree | | | | A01 | | |,|-|^|.| | |!| |!| | | | A01=Discharge }}
{{Familytree | | | | A01 | | |,|-|^|.| | |!| |!| | | | A01=Discharge }}
{{Familytree | | | | | | | | K02 | | K03 |!| |!| | | |K01=K01| K02= [[Bleeding]] controled| K03= [[Bleeding]] resume }}
{{Familytree | | | | | | | | K02 | | K03 |!| |!| | | |K01=K01| K02= [[Bleeding]] controled| K03= [[Bleeding]] resume }}
Line 151: Line 151:
{{Familytree | | | | | | | | |!| | | | | E02 | | | |E01=E01| E02=Appropriate intervention which may include [[embolization]], [[Surgery]], Additional  [[Nasal packing]] or [[Cautery]]}}
{{Familytree | | | | | | | | |!| | | | | E02 | | | |E01=E01| E02=Appropriate intervention which may include [[embolization]], [[Surgery]], Additional  [[Nasal packing]] or [[Cautery]]}}
{{Familytree | | | | | | | | |!| | | | | |!| | | | | | | }}
{{Familytree | | | | | | | | |!| | | | | |!| | | | | | | }}
{{Familytree | | | | | | | | |`|-|-|-|-| F01 |-|-| F02 |-|-| F03 | | | |F01=Patient Education and [[Prevention]]| F02=Outcome Assesment| F03=Discharge}}
{{Familytree | | | | | | | | |`|-|-|-|-| F01 |-|-| F02 |-|-| F03 | | | |F01=[[Patient]] Education and [[Prevention]]| F02=Outcome Assesment| F03=Discharge}}
{{familytree/end}}
{{familytree/end}}


* [[ABC]]= [[Airway]], [[Breathing]], [[Circulation]]
*'''[[ABC]]'''= [[Airway]], [[Breathing]], [[Circulation]]
* [[HHT]] = [[Hereditary Hemorrhagic Telangiectasia]]
*[[HHT]] = [[Hereditary Hemorrhagic Telangiectasia]]
 
{|
{|
! colspan="2" style="background:#DCDCDC;" align="center" + |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.
! colspan="2" style="background:#DCDCDC;" align="center" + |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==
==Do's==
* Assess [['''ABC''']] <ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref>


* [[Absorbable]] packs are preferred in children because the removal of the [[nonabsorbable]] pack is difficult.  
*Assess '''[[ABC]]''' <ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref>
* Before [[Nasal]] [[cautery]] [[anesthetize]] the [[bleeding]] area and limit [[cauterization]] just to the [[bleeding]] site.
 
* Remove [[blood clot]]s before [[rhinoscopy]].
*[[Absorbable]] packs are preferred in children because the removal of the [[nonabsorbable]] pack is difficult.
* Educate patients and their [[caregiver]]s about [[preventive method]]s for [[epistaxis]].
*Before [[Nasal]] [[cautery]] [[anesthetize]] the [[bleeding]] area and limit [[cauterization]] just to the [[bleeding]] site.
*Remove [[blood clot]]s before [[rhinoscopy]].
*Educate [[patients]] and their [[caregiver]]s about [[preventive method]]s for [[epistaxis]].


==Don'ts==
==Don'ts==
* Discontinue [[anticoagulant]] medications or reverse [[anticoagulation]] before cost-benefit assessment.<ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref>


* Give additional does of anticoagulant in active bleeding.
*Discontinue [[anticoagulant]] medications or reverse [[anticoagulation]] before cost-benefit assessment.<ref name="TunkelAnne2020">{{cite journal|last1=Tunkel|first1=David E.|last2=Anne|first2=Samantha|last3=Payne|first3=Spencer C.|last4=Ishman|first4=Stacey L.|last5=Rosenfeld|first5=Richard M.|last6=Abramson|first6=Peter J.|last7=Alikhaani|first7=Jacqueline D.|last8=Benoit|first8=Margo McKenna|last9=Bercovitz|first9=Rachel S.|last10=Brown|first10=Michael D.|last11=Chernobilsky|first11=Boris|last12=Feldstein|first12=David A.|last13=Hackell|first13=Jesse M.|last14=Holbrook|first14=Eric H.|last15=Holdsworth|first15=Sarah M.|last16=Lin|first16=Kenneth W.|last17=Lind|first17=Meredith Merz|last18=Poetker|first18=David M.|last19=Riley|first19=Charles A.|last20=Schneider|first20=John S.|last21=Seidman|first21=Michael D.|last22=Vadlamudi|first22=Venu|last23=Valdez|first23=Tulio A.|last24=Nnacheta|first24=Lorraine C.|last25=Monjur|first25=Taskin M.|title=Clinical Practice Guideline: Nosebleed (Epistaxis)|journal=Otolaryngology–Head and Neck Surgery|volume=162|issue=1_suppl|year=2020|pages=S1–S38|issn=0194-5998|doi=10.1177/0194599819890327}}</ref>
* After nasal [[packing]] don't educate the patient or caregiver about nasal [[packing]] sustenance.
 
*Give additional dose of [[anticoagulant]] in active [[bleeding]].
*After nasal [[packing]] don't educate the [[patient]] or caregiver about nasal [[packing]] sustenance.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Help]]
[[Category:Projects]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Up-To-Date]]

Latest revision as of 23:06, 27 October 2020

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?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anesthesia bleeding site and limit Nasal cautery to site
 
 
 
 
 
 
 
Yes→ Anesthesia 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.