What is the initial workup for a patient presenting with epistaxis (nosebleed)?

Initial Workup for Epistaxis

The initial workup for epistaxis should begin with immediate triage to determine if the patient requires emergent versus routine evaluation, followed by anterior rhinoscopy to identify the bleeding source, with laboratory testing reserved for patients with severe bleeding, anticoagulation use, or suspected bleeding disorders. 1

Immediate Triage Assessment

Determine acuity based on active bleeding status and hemodynamic stability:

• Emergent evaluation required: Active bleeding with airway compromise, hemodynamic instability (systolic BP <90 mmHg, drop >40 mmHg, orthostatic changes, tachycardia), or signs of significant blood loss 1, 2
• Prompt ambulatory evaluation: Minor active bleeding without airway or hemodynamic compromise, but patient has clinical expertise and supplies available 1
• Routine office evaluation: No active bleeding, prior bleeding was minor, no concern for severe recurrence 1

Critical History Elements

Document specific factors that predict severity and guide management:

• Bleeding characteristics: Duration >30 minutes over 24 hours indicates severe epistaxis; >3 recent episodes suggests need for specialist evaluation 1, 3
• Medication history: Anticoagulants (15% of epistaxis patients), antiplatelet agents—these patients require resorbable packing if intervention needed 1, 4
• Comorbidities: Hypertension (33% of epistaxis patients), cardiovascular disease, renal disease, liver disease, anemia, bleeding disorders 1, 2
• Prior epistaxis management: History of hospitalization, blood transfusion, or recurrent bilateral nosebleeds (suggests hereditary hemorrhagic telangiectasia) 1
• Family history: Recurrent nosebleeds in family members warrants assessment for telangiectasias 1

Physical Examination

Perform systematic visualization to identify bleeding source:

Anterior Rhinoscopy (Essential First Step)

• Remove blood clots first before attempting to visualize the bleeding site 1
• Examine nasal septum: Most nosebleeds originate from anterior septum (Kiesselbach's plexus/Little's area) 1
• Assess for visible bleeding point, telangiectasias, masses, or mucosal abnormalities 1

Nasal Endoscopy (Selective Use)

• Perform or refer for nasal endoscopy when: Bleeding is difficult to control, concern for unrecognized pathology (tumors, vascular malformations), or anterior rhinoscopy fails to identify source 1
• Examine nasopharynx and posterior nasal cavity for posterior bleeding sources (5% of epistaxis cases, more common in elderly) 1

Oral Cavity Examination

• Assess for oral mucosal telangiectasias in patients with recurrent bilateral epistaxis or positive family history (hereditary hemorrhagic telangiectasia screening) 1

Laboratory Testing

Laboratory workup is NOT routine—reserve for specific clinical scenarios:

Indications for Laboratory Testing

• Complete blood count (CBC): Obtain in patients with frequent/profuse bleeding to assess for anemia and quantify blood loss severity 2
  • Hemoglobin drop ≥2 g/dL indicates major bleeding requiring aggressive management 2
• PT/INR and aPTT: Obtain in all patients on anticoagulation or with clinically relevant bleeding 2, 5
  • Coagulation screening useful specifically in patients on anticoagulant medication 5
• Consider bleeding disorder workup: Only if history suggests inherited bleeding disorder (von Willebrand disease, hemophilia) or recurrent unexplained bleeding 1

When Laboratory Testing is NOT Indicated

• Routine blood tests in uncomplicated epistaxis do not reveal unsuspected abnormalities or change management 6
• Sinus X-rays are not indicated in routine epistaxis workup 6

Documentation Requirements

Record specific factors that increase bleeding frequency or severity:

• Bleeding duration, frequency, and estimated volume 1
• Anticoagulation/antiplatelet medication use 1
• Comorbid conditions (hypertension, cardiovascular disease, renal disease) 1
• Prior treatments attempted and their effectiveness 1
• Document outcome of intervention within 30 days or document transition of care 1

Critical Pitfalls to Avoid

• Do not perform routine coagulation studies in patients without anticoagulation use or bleeding disorder history—this does not change management 6, 5
• Do not skip clot removal before attempting visualization—this prevents accurate identification of bleeding source 1
• Do not delay hospital transfer in patients with hemodynamic instability or severe thrombocytopenia 4, 2
• Do not use non-resorbable packing in patients with bleeding disorders or on anticoagulation—use resorbable materials instead 1, 4