Epistaxis resident survival guide

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

Synonyms and keywords:

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.

Causes

Base on the cause and severity of Epistaxis it can be life-threatening.

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

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.[1] [2]

 
 
 
 
 
 
 
 
 
 
 
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 undelying 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 cause of epistaxis(17%)
❑ Digital trauma
Facial trauma
Foreign body insertion
Septal perforation
Barotrauma
❑ Illicit drugs
 
 
 
 

❑Using Anticoagulants or Antiplatelet medications
ITP*
von Willebrand disease
Leukemia
❑ Other medications cause coagulopathy
 
 
 
 
 
 
 


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

This algorithm modified and developed according to Epistaxis of Emergency Medicine Clinics of North America and Clinical Practice Nosebleed (Epistaxis) Guideline, This guideline was published in 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.

Statement Action Strength

 
 
 
 
 
 
 
 
 
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 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
 
 
 
 
 
 
 
 
 
 
 
 
  • ABC= Airway, Breathing, Circulation
    • HHT= Hereditary Hemorrhagic Telangiecstasia

-This algorithm modified and developed according to 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

  • The content in this section is in bullet points.

Don'ts

  • The content in this section is in bullet points.

References

  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. 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.


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