What is the workup for epistaxis (nose bleeding)?

Workup for Epistaxis (Nosebleed)

Initial Assessment and Triage

The first priority is to determine if the patient requires emergent versus routine evaluation by assessing for airway compromise, hemodynamic instability, or signs of significant blood loss. 1

Immediate Severity Assessment

• Assess for life-threatening features: Look for bleeding into the oropharynx causing airway compromise, signs of hypovolemia (tachycardia, syncope, orthostatic hypotension), or hemodynamic instability requiring emergent hospital evaluation 1
• Quantify bleeding severity: Bleeding duration >30 minutes over 24 hours, bilateral bleeding, bleeding from the mouth, history of hospitalization for epistaxis, prior transfusion, or >3 recent episodes indicate need for prompt evaluation 1
• Determine appropriate care setting: Active bleeding with airway/hemodynamic concerns requires emergency department; minor active bleeding can be managed in ambulatory setting with appropriate expertise and supplies; no active bleeding with minor prior episodes can be seen in routine office setting 1

History Documentation

Document specific risk factors that increase bleeding frequency or severity, as these directly guide management decisions. 1

Essential Historical Elements

• Medication history: Anticoagulant or antiplatelet medications (warfarin, DOACs, aspirin, clopidogrel) 1
• Bleeding disorder assessment: Personal history of bleeding from other sites, family history of bleeding disorders or recurrent nosebleeds 1
• Intranasal drug use: Cocaine, nasal steroids, or other intranasal substances 1
• Comorbid conditions: Hypertension, cardiopulmonary disease, anemia, liver or kidney disease 1
• Pattern of epistaxis: Unilateral versus bilateral, frequency, prior treatments attempted 1

Physical Examination

Perform anterior rhinoscopy after removing any blood clot to identify the bleeding source, as localization determines treatment approach. 1

Systematic Nasal Examination

• Remove clot first: Clear the nasal cavity of blood clots before attempting to visualize the bleeding site 1
• Anterior rhinoscopy: Examine the anterior nasal cavity systematically, focusing on Kiesselbach's plexus (anterior septum) where most bleeds originate 1
• Assess for telangiectasias: In patients with recurrent bilateral nosebleeds or family history of recurrent epistaxis, examine for nasal and oral mucosal telangiectasias to screen for hereditary hemorrhagic telangiectasia (HHT) 1

Advanced Visualization When Indicated

• Nasal endoscopy: Perform or refer for nasal endoscopy in patients with difficult-to-control epistaxis, recurrent bleeding despite prior treatment with packing or cautery, or concern for unrecognized pathology (tumor, vascular malformation) 1
• Nasopharyngeal examination: Endoscopy allows visualization of posterior bleeding sources and nasopharynx that cannot be seen with anterior rhinoscopy alone 1

Laboratory and Imaging Workup

While the guidelines focus primarily on clinical assessment, certain situations warrant additional workup:

• Consider coagulation studies: In patients with suspected bleeding disorders, family history of bleeding, or bleeding refractory to standard measures 1
• Hemoglobin/hematocrit: For patients with signs of significant blood loss, prolonged bleeding, or hemodynamic changes 1
• Imaging is not routinely indicated: Reserve for cases with suspected underlying pathology (tumor, vascular malformation) identified on endoscopy 1

Documentation Requirements

Document the outcome of intervention within 30 days or document transition of care for patients treated with nonresorbable packing, surgery, or arterial ligation/embolization. 1

Key Documentation Elements

• Bleeding severity and duration 1
• Risk factors identified 1
• Bleeding site location (if identified) 1
• Interventions performed 1
• Patient education provided 1
• Follow-up plan 1

Critical Pitfalls to Avoid

• Do not skip clot removal: Attempting to visualize the bleeding site without first removing clots prevents accurate localization 1
• Do not assume anterior source: Posterior bleeds are more dangerous and require different management; if anterior examination is negative but bleeding continues, consider posterior source 1
• Do not overlook bilateral bleeding: Recurrent bilateral epistaxis warrants assessment for HHT, which has significant systemic implications 1
• Do not delay endoscopy in refractory cases: Persistent or recurrent bleeding despite initial treatment requires endoscopic evaluation to identify the source and guide definitive management 1