Epistaxis Management (AAO-HNSF 2020)

Algorithm Steps

1. ▶

   Start

   Patient with Active Epistaxis

   Patient presents with nasal bleeding

   1. ◆

      Decision

      Hemodynamically Stable?

      Assess airway, breathing, circulation. Check for signs of significant blood loss: hypotension, tachycardia, pallor

      1. ⚠

         Warning

         ⚠️ Resuscitate First

         IV access, fluids, type and cross. Consider blood transfusion. Apply bilateral anterior packing while stabilizing.

         1. ●

            Action

            Apply Sustained Compression

            Pinch lower third of nose firmly for 5+ minutes continuously (KAS 2). Patient sitting forward, mouth breathing.

            • Pinch soft cartilaginous portion (not bony bridge)
            • Minimum 5 minutes uninterrupted
            • Patient leans forward to prevent swallowing blood
            1. ◆

               Decision

               Bleeding Stopped?

               Release compression after 5 minutes. Check if bleeding has ceased.

               1. ●

                  Action

                  Document & Counsel

                  Document bleeding history, anticoagulant use (KAS 5). Counsel on prevention: humidification, nasal saline, avoid picking (KAS 13).

                  1. ✓

                     Outcome

                     Bleeding Controlled

                     Document outcome within 30 days (KAS 14). Arrange follow-up for packing removal if non-resorbable used.

               2. ●

                  Action

                  Anterior Rhinoscopy

                  After clot removal, perform anterior rhinoscopy to identify bleeding source (KAS 6). Use headlight, nasal speculum.

                  • Clear clots with suction
                  • Apply topical vasoconstrictor (oxymetazoline)
                  • Identify source: Kiesselbach plexus most common
                  1. ◆

                     Decision

                     Bleeding Source Identified?

                     Can you visualize an anterior bleeding point?

                     1. ●

                        Action

                        Cauterize Bleeding Site

                        Apply topical anesthetic, then silver nitrate or electrocautery to active/suspected bleeding site only (KAS 9). Cauterize one side only to avoid septal perforation.

                        1. ◆

                           Decision

                           On Anticoagulation/Antiplatelet?

                           Is patient on warfarin, DOACs, aspirin, clopidogrel, or has bleeding disorder?

                           1. ●

                              Action

                              Use Resorbable Packing

                              For patients on anticoagulation or with bleeding disorders, use resorbable packing materials (KAS 3b): Gelfoam, Surgicel, or FloSeal.

                              1. ◆

                                 Decision

                                 Bleeding Controlled with Packing?

                                 Is bleeding adequately controlled after packing placement?

                                 1. ⚠

                                    Warning

                                    ⚠️ Escalate Care

                                    Refer for surgical arterial ligation or endovascular embolization (KAS 10). Consider posterior packing as temporizing measure. ENT and IR consultation.

                                 2. ◆

                                    Decision

                                    Recurrent Bilateral Bleeds?

                                    Screen for nasal/oral telangiectasias and family history for hereditary hemorrhagic telangiectasia (KAS 12).

                                    1. ✓

                                       Outcome

                                       Refer for HHT Workup

                                       Refer to genetics/HHT center if Curaçao criteria met: epistaxis, telangiectasias, visceral AVMs, family history.

                           2. ●

                              Action

                              Non-Resorbable Packing

                              Apply anterior nasal packing (KAS 3a): Merocel, Rapid Rhino, or ribbon gauze. Educate patient on packing care and removal timing (KAS 4).

                              • Typical removal: 24-48 hours
                              • Prophylactic antibiotics controversial
                              • Return precautions: fever, worsening pain
                     2. ●

                        Action

                        Nasal Endoscopy

                        Perform nasal endoscopy to locate posterior or obscured bleeding sites (KAS 7a). Required for recurrent or unilateral epistaxis despite prior treatment.