What is the approach to managing epistaxis (nosebleed) in the emergency room (ER), including initial patient assessment, laboratory tests to order, and treatment options?

Approach to Epistaxis in the Emergency Room

The initial management of epistaxis in the emergency room should involve patient stabilization, followed by direct nasal compression for 10-15 minutes, application of topical vasoconstrictors, and anterior nasal cautery for visible bleeding sites. 1

Initial Patient Assessment

Vital Signs and Hemodynamic Status

• Assess airway patency, breathing, and circulation
• Check vital signs: blood pressure, heart rate, oxygen saturation
• Evaluate for signs of hemodynamic instability (tachycardia, hypotension, syncope)
• Position patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1

Key History Elements

• Duration and severity of current bleeding episode
  • Bleeding >30 minutes over 24 hours is considered severe 1
  • History of hospitalization for nosebleeds
  • Prior blood transfusion for nosebleeds
  • ≥3 recent episodes of nasal bleeding
• Bleeding from one or both sides of the nose
• Trauma history (recent nasal/facial trauma, digital manipulation)
• Medication use, particularly:
  • Anticoagulants (warfarin, DOACs)
  • Antiplatelet agents (aspirin, clopidogrel)
  • NSAIDs 1
• Medical conditions:
  • Hypertension (present in 33% of epistaxis cases) 1
  • Coagulation disorders (present in 0.9% of cases) 1
  • Liver or kidney disease
  • Hereditary hemorrhagic telangiectasia (HHT)

Physical Examination

• Use adequate lighting (headlamp) and nasal speculum 2
• Determine if bleeding is anterior (90-95% of cases) or posterior (5-10%)
• Identify bleeding site if visible (Kiesselbach's plexus is most common for anterior epistaxis) 1
• Assess for nasal deformities, septal deviation, or masses
• Look for signs of facial fractures if trauma-related 1

Laboratory Tests to Order

Essential Tests

• Complete blood count (CBC) to assess for anemia and platelet count
• Coagulation studies (PT/INR, PTT) especially for patients on anticoagulants
• Type and cross-match if significant blood loss or ongoing severe bleeding

Additional Tests Based on Clinical Suspicion

• Liver function tests if liver disease suspected
• Renal function tests if kidney disease suspected
• Specialized coagulation studies if bleeding disorder suspected

Treatment Algorithm

1. First-Line Management for Anterior Epistaxis

• Have patient sit upright with head tilted slightly forward 1
• Apply direct pressure by pinching the soft part of the nose continuously for 10-15 minutes 1
• Apply vasoconstrictor agents:
  • Oxymetazoline spray or cotton soaked in oxymetazoline/epinephrine 1:1000 2
• Identify bleeding site using adequate lighting and nasal speculum

2. Cauterization for Visible Bleeding Sites

• Silver nitrate cauterization has the highest success rate (80%) for anterior epistaxis 3
• Apply to visible bleeding vessels after topical anesthesia
• Avoid bilateral cauterization to prevent septal perforation 1

3. Nasal Packing for Persistent Bleeding

• For anterior epistaxis:
  • Commercial anterior packing (e.g., Merocel®)
  • Petroleum gauze packing
• For posterior epistaxis:
  • Commercial posterior packing devices
  • Consider early referral to otolaryngology as posterior epistaxis has higher hospitalization rates 2

4. Advanced Interventions (if available or with specialist consultation)

• Endoscopic identification and cauterization of bleeding vessels
• Arterial ligation (sphenopalatine artery) for refractory cases
• Endovascular embolization procedures

Special Considerations

Patients on Anticoagulants

• Patients on anticoagulants should seek medical attention for epistaxis 1
• Consult with appropriate specialists before adjusting anticoagulation
• Consider checking anticoagulation levels (INR for warfarin)
• Have reversal protocols available for severe bleeding

Hypertension Management

• Control severely elevated blood pressure but avoid aggressive reduction
• The causal relationship between hypertension and epistaxis is not well established 1

Discharge Criteria and Follow-up

• Bleeding controlled for at least 1 hour
• No signs of hemodynamic instability
• Patient able to return if bleeding recurs
• Follow-up recommended for patients who underwent invasive treatments 1
• Patient education about secondary symptoms requiring additional follow-up (nasal blockage, pain, severe crusting) 1

Common Pitfalls to Avoid

• Failing to identify posterior epistaxis, which requires more aggressive management
• Inadequate duration of direct pressure (minimum 10-15 minutes)
• Bilateral simultaneous septal cautery, which increases risk of septal perforation 1
• Overlooking anticoagulant medications as contributing factors
• Discharging patients too early before ensuring bleeding is controlled
• Not providing clear discharge instructions about when to return

By following this systematic approach to epistaxis management in the emergency room, clinicians can effectively control bleeding while minimizing complications and recurrence rates.